Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care provided March 11, 2023, to 
March 13, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee presented to the 
emergency department. The Plan denied your request. The Plan says they were not notified of the admission 
until after the enrollee was discharged. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found due to the enrollee's quick recovery and stable hemodynamics, it was not expected 
that the enrollee would require hospitalization that would likely cross two midnights. Observation status would 
have been more appropriate for this enrollee according to the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care provided March 11, 2023, to March 13, 2023. 
 
The Plan has only denied March 12, 2023, to March 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 21, 2022, 
to October 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 21, 2022, to 
October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT solid tumor assay provided on January 6, 
2023. 
 
You asked the Plan to pay for the Tempus xT solid tumor assay. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the limited records submitted do not support advanced, 
refractory, metastatic or recurrent Stage III or IV cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Tempus xT solid tumor assay have 
been met. Specifically, medical records were not submitted for review. Without these records we are unable to 
verify medical necessity for this testing. Therefore, we decided that the Plan does not have to pay for the 
Tempus xT solid tumor assay provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve neurolysis. 
 
You asked the Plan to pre-approve genicular nerve neurolysis. You say that it is medically necessary. The Plan 
denied your request. The Plan says the requested service does not meet the requirements for approval. 
 
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 neurolysis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  
 
Our physician reviewer found this procedure is the subject of ongoing clinical trials and is considered 
experimental at this time.  Therefore, the request is deemed not medically reasonable and necessary. 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 neurolysis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve neurolysis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 28, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until March 16, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 for date of service January 28, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 99291 is not payable as billed. Specifically, this service was billed with a primary 
diagnosis code of J68.0. Diagnosis code J68.0 has a "code first" note which requires the underlying condition to 
be sequenced first. The claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure code 99291 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99291 for date of service January 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service March 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documents prove medical necessity. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service March 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria under CMS guidelines. The Plan denied your request. The Plan says it is not safe to leave the 
hospital currently because the enrollee has a chest tube that requires further monitoring and management the 
current hospital prior to discharge. The enrollee is receiving the care you needed in the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 enrollee is not able to be discharged without 
being admitted to inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 16, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests are separately 
billable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee has completed physical 
therapy for knee pain. You say that the enrollee does the home exercise program, but it is not helpful.  The Plan 
denied your request. The Plan says a genicular nerve block is 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 a genicular nerve block. Our reviewer 
says that a genicular nerve block is not medically necessary. Our physician reviewer found that the enrollee has 
a history if right knee pain due to osteoarthritis. The enrollee has been treated with medication, chiropractic 
care, and has undergone a right knee genicular nerve radiofrequency ablation on the lateral genicular nerve, 
medical superior genicular nerve, and medial inferior genicular nerve on May 2, 2023. However, genicular 
nerve blocks and genicular nerve ablations are considered investigational and not medically necessary for 
treatment of chronic 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the item should be covered. The Plan denied 
your request. The Plan says there is no evidence an in-person evaluation took place. 
 
The Plan must follow Medicare rules. Medicare rules say that if a positive airway pressure (PAP) device is 
replaced following the 5 year reasonable useful lifetime (RUL), there must be an in-person evaluation by their 
treating practitioner that documents that the beneficiary continues to use and benefit from the PAP device.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, there is no evidence an in-person evaluation took 
place. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure 
(CPAP) device (E0601).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept; thermal destruction of intraosseous 
basivertebral nerve at L4-L5. 
 
You asked the Plan to pre-approve an Intracept. You say that the enrollee would benefit from this procedure. 
The Plan denied your request. The Plan says medical studies do not show that this procedure works better than 
others. 
 
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 an Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging showing only modic changes and no facet joint disease 
or foraminal stenosis. The cause of back pain is not clear.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept; thermal destruction of intraosseous basivertebral nerve at L4-L5.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. 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 TMS is covered when specific criteria are met. 
 
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 TMS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the information provided, this 
enrollee does not meet the clinical criteria for the use of Transcranial Magnetic Stimulation (TMS) therapy 
utilizing LCD (L36469) as he is not diagnosed with having major depressive disorder severe. It is unclear the 
titration of medication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcranial magnetic stimulation (TMS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-electric seat lift mechanism (E0629). 
 
You asked the Plan to pre-approve a non-electric seat lift mechanism. You say that a non-electric seat lift 
mechanism is a medical necessity for the enrollee. The Plan denied your request. The Plan says a non-electric 
seat lift mechanism is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 a non-electric seat lift mechanism. Our reviewer says that a non-electric seat lift mechanism is not medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not have: (a) severe arthritis of the hip; and/or (b) a 
neuromuscular disease. The records do not show that a seat lift is included in the treating practitioner's course 
of treatment. The requested seat lift is not likely to (a) effect improvement in the enrollee's condition; or (b) 
arrest or retard deterioration in the enrollee's condition. The records do not show that the enrollee is completely 
incapable of standing from a chair in the home. The records do not show that the enrollee has the ability to 
ambulate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a non-electric seat lift mechanism have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a non-electric seat lift mechanism (E0629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis. 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested MyoPro orthosis is medically 
necessary. The Plan denied your request. The Plan says the requested MyoPro orthosis is 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 a MyoPro orthosis. Our reviewer says 
that the requested MyoPro orthosis is not medically necessary. Our physician reviewer found the MyoPro 
orthosis is not known to be effective, based on scientific evidence, professional standards and expert opinion, in 
improving health outcomes. The MyoPro is not the standard of care for this enrollee's peripheral nerve injury or 
traumatic brain injury or in widespread use for this enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes for this 
enrollee. There is insufficient evidence in the literature that this device will increase participation in bi-manual 
activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) billed with codes 82310, 82728, 83540, 83550, 83970, and 84100 provided on January 11, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) billed with codes 
82310, 82728, 83540, 83550, 83970, and 84100 provided on January 11, 2023.