Persius/hicric huggingface dataset:
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee continued stay at acute hospital until the enrollee is stable 
enough for discharge to a lower level of care has not been denied. 
 
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 the enrollee appears to currently be somewhat unstable and requires additional 
acute care hospital services that can safely be provided at the current facility until more stable for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current facility. There are 
no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87507) billed for date of service 
March 1, 2023. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 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. In this case, we found that the requested testing is not designated as a 
covered service by the MolDX contractor. Based on this information, we decided that Medicare rules for 
coverage of infectious-agent testing have not been met. Therefore, we decided that the Plan does not have to 
pay for infectious-agent testing (87507) billed for date of service March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing (81226) provided on December 29, 
2022.  
 
You asked the Plan to pay for the GeneSight testing. You say that this testing helps eliminate ineffective 
therapy. The Plan denied your request. The Plan says this testing is not medically necessary.  
 
Medicare rules say that this testing is covered when the criteria in the rules section of this letter 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 pay for the GeneSight testing. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the documentation in multiple 
places very specifically states that the enrollee is being treated for acute embolism and thrombosis of 
unspecified deep veins of unspecified lower extremity. The test being ordered is a test to choose psychiatric 
medications. The enrollees diagnosis is not appropriate for psychotropic pharmacogenetic testing. The review 
has determined that the records do not support that the enrollee met the criteria in LCD L38394 for the testing. 
The services are not reasonable or medically 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 the GeneSight testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the GeneSight testing (81226) provided on December 29, 2022.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for anemia, pulmonary edema, gastrointestinal bleeding and encephalopathy. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
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 this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 10, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
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 outpatient claim was billed with code 99211, which is assigned a status indicator of B, and it 
not payable under OPPS. As such, the claim returned OCE edit 62. This edit denies the billed code, as well as 
the rest of the claim. 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 the services provided on 
January 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 11, 2022, 
to November 17, 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 is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 secondary diagnosis code E43, described as 
unspecified severe protein-calorie malnutrition. 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 code. Our physician reviewer found the enrollee is a 65-year-old male with chronic kidney 
disease due to membranous nephropathy and hypertension, and hepatitis C who presented to the hospital with 
urinary tract infection, acute on chronic kidney failure, and high blood pressure. He was treated with 
antihypertensives, paracentesis, Rituxan. Documentation revealed Body mass index 20.9. Documentation 
revealed some degree of muscle wasting with a history of an estimated 75% reduction in calorie intake over 
prior month and a weight loss of only one pound over the prior 3 months. He was treated with oral nutritional 
supplements in addition to diet in the hospital. Although there was a notable malnutrition, the diagnosis of 
severe protein-calorie malnutrition (E43) was not sufficiently supported as the patient was not sufficiently 
underweight, had not been eating less than 50% of required calories, and did not have a significant weight loss 
to meet criteria.   
 
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 November 11, 2022, to November 17, 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 Nuvasive Osteocel allograft (20930). 
 
You asked the Plan to pre-approve Nuvasive Osteocel allograft. You say that this is medically necessary. The 
Plan denied your request. The Plan says the medical necessity for the denied procedure has not been 
established after clinical review per the peer-reviewed medical literature. 
 
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 Nuvasive Osteocel allograft. 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 requested allograft to be an effective and/or safe treatment for the noted pathology. Further 
studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. 
There is no compelling rationale 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 Nuvasive Osteocel allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Nuvasive Osteocel allograft (20930).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot be safely discharged home. You require 
IRF services in order to get stronger and return home independent. The Plan denied your request. The Plan says 
the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve block. 
 
You asked the Plan to pre-approve a peripheral nerve block. You say that a peripheral nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested service 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 peripheral nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental and investigational at this time. 
 
  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 peripheral nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a peripheral nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices provided on February 3, 
2023. 
 
You asked the Plan to pay for the pneumatic compression devices. You say that this device was provided for 
use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
  The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression devices provided on February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87631) billed for date of service 
August 9, 2022. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the service at issue 
correctly. 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 infectious-agent 
testing have not been met. Therefore, we decided that the Plan does not have to pay for infectious-agent testing 
(87631) billed for date of service August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service December 
22, 2022.  
 
You asked the Plan to pay for procedure code 76942. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76942 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942 billed for date of service December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is appropriate for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral knee replacement surgery. 
 
You asked the Plan to pre-approve bilateral knee replacement surgery. You say that you have been housebound 
for over 3 years while your arthritis has been making your knees deteriorate to the point of bone-on-bone and 
crunch with every step. You say that the bilateral genicular nerve ablation procedure you received had no effect 
on your knee pain. You say that your research has shown that being overweight alone is not reason to deny 
total knee replacement surgery. You say that your physical therapist recommended the requested surgery.  The 
Plan denied your request. The Plan says knee surgery at the enrollee's current weight carries increased risks for 
surgery and those risks would need to be reviewed with orthopedics. The Plan says that the requested 
procedure is not medically necessary based on the records provided.  
 
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 bilateral knee replacement surgery. Our 
reviewer says that bilateral knee replacement surgery is not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, 
reasonable, comprehensive, less invasive conservative care measures is not evident. You have had cortisone 
injections; however, it is not clear when your last injection was. You have used medications and a genicular 
radiofrequency ablation (without benefit). However, there is no indication of any viscosupplementation 
injections and/or physical therapy or exercises. Additionally, there are no diagnostic imaging studies provided 
for review to corroborate bilateral knee pathology that could potentially benefit from the requested surgery. 
Moreover, you have an estimated body mass index of 46.59 Kilograms per square meter (kg/m2.) There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. 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 bilateral knee replacement surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bilateral knee replacement surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 26, 2023, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334, and 81351. 
 
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 
January 26, 2023, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334, and 81351.