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

 
We decided that the Plan does not have to pre-approve Axolotl Graft or Axolotl DualGraft (Q4210), and Celera 
Dual Layer or Celera Dual Membrane (Q4259). 
 
You asked the Plan to pre-approve Axolotl Graft or Axolotl DualGraft, and Celera Dual Layer or Celera Dual 
Membrane. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 Axolotl Graft or Axolotl DualGraft, and 
Celera Dual Layer or Celera Dual Membrane. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the wound is 
improving with the current wound care, with a reduction in size, area, and dimensions from July 26, 2023, to 
August 8, 2023, by more than 50%. The records clearly document that once the enrollee was offloading the 
wound, the wound appearance improved, with reduction in wound area from 15.0 square centimeters to 5.25 
square centimeters. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Axolotl Graft or Axolotl DualGraft, and Celera Dual Layer or Celera Dual 
Membrane have not been met. Therefore, we decided that the Plan does not have to pre-approve Axolotl Graft 
or Axolotl DualGraft (Q4210), and Celera Dual Layer or Celera Dual Membrane (Q4259).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Optune device (E0766), from January 26, 2023, through 
May 26, 2023. 
 
You asked the Plan to pay for the Optune device. You say that the item should be covered. The Plan denied 
your request. The Plan says you do not have a covered diagnosis for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of TTFT for any indications other than 
newly diagnosed glioblastoma multiforme (GBM) will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Optune device have not been met. Therefore, we decided that the Plan does not have to pay for 
the Optune device (E0766), from January 26, 2023, through May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 28, 2023, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 
81239. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 28, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, and 81239.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a failed discharge and is unable to 
cope in the home setting. The Plan denied your request. The Plan says the enrollee's condition does not meet 
Medicare guidelines for admission to an IR. 
 
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 that 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (76376) provided on November 12, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 radiology services have been met. 
No medical records were provided to show that a 3D rendering and interpretation were performed.  Therefore, 
we decided that the Plan does not have to pay for radiology services (76376) provided on November 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex interlaminar device (22867). 
 
You asked the Plan to pre-approve the Coflex interlaminar device. You say that this is medically necessary. 
The Plan denied your request. The Plan says current evidence-based medical guidelines and peer-reviewed 
literature do not fully support the spinal Coflex interlaminar/interspinous device procedure over/beyond the 
gold standard of lumbar laminectomy alone. 
 
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 the Coflex interlaminar device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Coflex device is experimental. More research is needed. 
 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 Coflex interlaminar device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Coflex interlaminar device (22867).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided May 
27, 2022, to July 31, 2022. 
 You asked the Plan to pay for an acute inpatient psychiatric hospitalization. You say that the total length of stay 
was medically necessary. The Plan denied your request. The Plan says this admission has been correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an acute inpatient psychiatric 
hospitalization. Our reviewer says that this admission was not medically necessary. Our physician reviewer 
found the records provided for the admission of this enrollee does not meet the criteria for May 27, 2022 
forward as this enrollee was not shown to be a danger to herself or others, delusions, auditory or visual 
hallucinations noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
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 acute inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided May 27, 
2022, to July 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has generalized weakness and difficulty 
walking and IRF services will help them achieve a high level of functioning. The Plan denied your request. The 
Plan says the enrollee's condition does not meet Medicare guidelines for services in an IRF. 
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided September 19, 2022, to 
September 22, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was admitted from the 
emergency department. The Plan denied your request. The Plan says that observation level of care would have 
been more appropriate. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided September 19, 2022, to September 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2023, billed with 
codes 81227, 81226, 81231, 81225, 81232, 81240, 81241, 81291, 81306, 81328, 81335, & 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 8, 2023, billed with codes 81227, 81226, 81231, 81225, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, & 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation of syncope and/or cryptogenic stroke. 
 
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 implantable loop recorder. 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 documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an implantable loop recorder. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve geniculate artery embolization. You say that this is medically necessary. 
The Plan denied your request. The Plan says this procedure is not an accepted standard of medical practice. 
 
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 geniculate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment. While the studies are noted to be promising, 
further studies/research is needed to corroborate that geniculate artery embolization is as good as or better than 
standard treatments for knee osteoarthritis. No compelling rationale is presented, or 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 geniculate artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve geniculate artery embolization (36246, 36247).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 testing billed for date of service May 23, 2022. 
 
You asked the Plan to pay for the billed services. You say that this testing is a payable service. The Plan denied 
your request. The Plan says that 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. A review of the claim does show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have been met. Therefore, we decided that the Plan has to pay for the Guardant360 testing billed for date of 
service May 23, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional hour of home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that you need the additional hours because two 
hours daily is too little time. You also say that this additional hour oversees you taking your  medications, 
which is medically necessary for your continuation of care. The Plan denied your request. The Plan says the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that you require assistance with activities of daily living skills and home health services 
which would be expected to be medically necessary. The documentation does not specify any additional 
service required to support an additional hour of home health service per day, 7 days per week. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional hour of home health aide services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive rehabilitation with 
daily physician management, continuous specialized rehabilitation nursing, and intensive therapies to optimize 
mobility and strengthening while ensuring the restoration of their functional status for a safe and sustainable 
discharge. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, 
tracheostomy management or neurogenic bowel and bladder management. The enrollees medical and 
rehabilitation needs do not require the intensive interdisciplinary approach provided in an IRF. 
  
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. The enrollee has had a decline from their baseline level of function and 
may benefit from occupational therapy and physical therapy as well as supervision and assistance, but does not 
require the intensity of therapies provided on acute inpatient rehabilitation. 
 
 
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 an IRF admission and services.