Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blood test to check for risk of rejection of a transplanted 
kidney (AlloSure). 
 
You asked the Plan to pre-approve blood test. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve blood test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of renal transplant in 2014 for autosomal dominant polycystic 
kidney disease. The enrollee was evaluated on February 1, 2023, and the office visit notes indicated that the 
enrollees most recent creatinine level was close to his baseline.  The enrollee was instructed to continue immunosuppressive medications and to recheck lab work in three 
months. The enrollee had been evaluated on August 24, 2022 and the office visit notes said that the most recent 
creatinine was 1.67. The records received did not indicate a concern for risk of rejection of the transplanted 
kidney, or detail any symptoms of rejection. The records also did not indicate that there is current consideration 
for a future kidney biopsy. There is no specific clinical rationale for the requested laboratory study. Therefore, 
the enrollee does not meet criteria for the requested services. 
 
The Plan uses Local Coverage Determination (LCD) L38355, LCD L38629, and Local Coverage Article 
(LCA) A58168 to support their denial. LCD L38355, LCD L38629, and LCA A58168 are not valid for the 
enrollees home state of Kansas. Therefore, we cannot use LCD L38355, LCD L38629, or LCA A58168 to 
substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blood test have not been met. Therefore, we decided that the Plan does not have 
to pre-approve blood test to check for risk of rejection of a transplanted kidney (AlloSure).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that these additional benefits would be very 
helpful for you. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you need these extra benefits. The Plan denied 
your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found your current back pain is not clearly 
documented to be primarily due to the identified L1 compression deformity. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, you do not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J1335 and J1642 billed for date of service 
July 3, 2022. 
 
You asked the Plan to pay for procedure codes J1335 and J1642. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  We find that procedure codes J1335 and J1642 are not supported. Specifically, the codes at issue have a status 
indicator of N in the Outpatient Prospective Payment System (OPPS). It is inappropriate to report these codes 
for separate payment. Based on this information, we decided that Medicare rules for coverage of procedure 
codes J1335 and J1642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes J1335 and J1642 billed for date of service July 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are necessary as you are at a high risk 
for re-admission. The Plan denied your request. The Plan says your needs can be met in an alternative level of 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624). 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that genicular nerve ablation is experimental for knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve ablation procedure (64624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement rendered on February 6, 2023. 
 
You asked the Plan to pay for the services. You say that this code is reimbursed separately. The Plan denied 
your request. The Plan says the services rendered do not meet the established criteria for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 36227 is "Selective catheter placement, external carotid 
artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological 
supervision and interpretation (List separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records attached do not support the use of CPT 36227. The medical record did not indicate when the provider advances the catheter 
into the abdominal aorta, further up into the thoracic aorta, then that he manipulates further into the internal 
carotid, common carotid or innominate atery of any one side and injects the contrast material. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for selective catheter placement rendered on February 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 25, 2022, to 
April 14, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.50, described as 
Gram-negative sepsis, unspecified, and secondary diagnosis code R65.20, described as Severe sepsis without 
septic shock. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the 
DRG originally billed. Our reviewer says that documentation does not support the billed codes. Our physician 
reviewer found the enrollee is a 76-year-old female with a history of cerebral vascular accident who presented 
to the hospital with hematuria, abdominal pain and was diagnosed with urinary tract infection, and possible 
cholecystitis. She was started on fluids and antibiotics and underwent cholecystectomy. The notes describe the 
enrollee as being at mental status baseline with Glasgow Coma Scale of 12, creatinine was elevated and blood 
pressure reduced but each improved with fluids and blood transfusion post-surgery, a mild bilirubin elevation 
was related to cholecystitis, she was not hypoxic, and platelets were normal. The direct effects of fluid 
depletion, anesthesia, cholecystitis, were causing the findings observed and were not related to a dysregulated 
response to infection causing organ damage based on the records provided, Sepsis 3 criteria is not met. 
Therefore, diagnosis codes, A41.5 (gram negative sepsis) or R65.2 (severe sepsis) are not supported by the 
documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 25, 2022, to April 14, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery services (22633, 22840, 22853 and 
63052). 
 
You asked the Plan to pre-approve spinal surgery services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve spinal surgery services. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive, conservative care measures is not evident. Additionally, dynamic flexion/extension films did not demonstrate movement (instability) at the requested surgical level. Detailed 
documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. No 
compelling rationale is presented nor extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal surgery services (22633, 22840, 22853 and 63052).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
June 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support procedure code 99233. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that no records have been identified 
for the date of service in question. As such, there is no evidence that the services were provided and meet the 
billing criteria. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered on June 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from June 21, 2022, to July 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that certain diagnosis codes are exempt from reporting a POA indicator. Either no 
entry or an entry of 1 in the POA indicator field is required for these diagnoses. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, diagnosis code Z01.818 is on the POA exempt list. As such, no 
entry in the POA indicator field is appropriate for payment to be made. Therefore, we decided that the Plan has 
to pay for the services provided from June 21, 2022, to July 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's current needs can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable. While the enrollee may benefit from physical and 
occupational therapy, their rehab needs can be provided in a lower intensity and alternate setting such a as in-
home with services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's rehab and medical needs may be met with part-time skilled 
services at an alternative level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97760 provided on March 1, 2022. 
 
You asked the Plan to pay for procedure code 97760. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97760 is Orthotic(s) management and training (including 
assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, 
initial orthotic(s) encounter, each 15 minutes. 
 
We find that CPT code 97760 is not supported in the medical record. Specifically, the records provided make 
no mention of an orthotic being fitted or training being performed. The plan requested additional records and 
none were provided. Based on this information, we decided that Medicare rules for coverage of procedure code 97760 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 97760 
provided on March 1, 2022.