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

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) radiofrequency ablation (RFA) 
(64625). 
 
You asked the Plan to pre-approve SIJ RFA. You say that the service is necessary. The Plan denied your 
request. The Plan says the requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SIJ RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve 
sacroiliac joint (SIJ) radiofrequency ablation (RFA) (64625).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device (33289, C2624).
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says you do not meet the 
guidelines for care in an LTACH.  
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The Plan has approved ongoing care 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 long term acute care hospital (LTACH) services.
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 the enrollee continues to have medical 
and cardiac needs that exceed skilled nursing facility capabilities and requires an LTACH stay. The Plan denied 
your request. The Plan says the LTACH services requested do not meet the requirements for approval.  
 
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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0422 & A0425) provided on 
December 2, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code A0422 & A0425 is not supported in the medical record. Specifically, the claim only 
included a mileage and supplemental code. No base ambulance transport code was billed. Based on this 
information, we decided that Medicare rules for coverage of the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0422 & A0425) provided 
on December 2, 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 IRF services are necessary because the enrollee has 
multiple medical conditions, and you believe they need 3 hours of intensive physical therapy daily as opposed 
to 1.5 hours of therapy at a sub-acute rehabilitation facility. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for admission to the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 9, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that outpatient diagnostic tests require prior authorization. 
 
We looked at the file and Medicare rules. The services at issue were not authorized. Based on this information, 
we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for laboratory services provided on January 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered outside of a 
Medicare-approved study. 
 
There is no evidence that the enrollee is in an approved study. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a leadless pacemaker.
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 you have been in the hospital for over five weeks 
and have lost strength in your legs and have weakness. You say in inpatient rehabilitation, you will receive 
physical and occupational therapy to aid you in regaining strength, muscle endurance and the ability to transfer.  
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve the drug. You say that this drug is medically necessary to treat 
chemotherapy-related anemia. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
microcytic anemia and is being treated for metastatic colon cancer with FOLFOX and Bevacizumab. Other 
sources of anemia, specifically iron deficiency (the enrollee is on B12 injections) have not been ruled out. The 
service is 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided from 
November 25, 2021, to December 25, 2021. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that you have billed the items at issue 
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 claims must specify whether equipment is rented 
or purchased. 
  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electrical stimulator supplies have not been met. Specifically, the claim line for the items at issue 
does not contain a modifier to specify whether the equipment is rented or purchased. Therefore, we decided 
that the Plan does not have to pay for electrical stimulator supplies (A4595) provided from November 25, 2021, 
to December 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 30 units of code B4034 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for 30 units of code B4034. You say that the billed items represent a 30-day span of 
services. The Plan denied your request. The Plan says you billed too many units of this code on a single claim 
line. 
 
The Plan must follow Medicare rules. Medicare rules say that the unit of service (UOS) for code B4034 is one 
(1) UOS per day.  
 
In this case, you billed 30 units of code B4034 on a single claim line, and only indicated a single date of 
service.  In order to be paid, the individual day units of this code will either need to be billed on separate claim 
lines, OR the dates of service billed will need to indicate the range of dates to which this code applies.  You did 
not do either of these things on this claim.  Because of this, your claim indicates 30 units of service billed for a single date of service, which is not allowable under the rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 30 units of code B4034 have not been met. Therefore, we decided that the Plan does not have to 
pay for 30 units of code B4034 billed for date of service September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the unlisted molecular pathology procedure (PrismRA) 
(81479) provided January 11, 2023. 
 You asked the Plan to pay for  the laboratory service. You say that please find the appeal information that 
describes the medical necessity of the PrismRA test to inform consideration of payment. The Plan denied your 
request. The Plan says PrismRA has not been cleared or approved by the FDA approved test and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Under Medicare guidelines, this test is not medically necessary 
because this test is not Food and Drug Administration (FDA) approved and based on the diagnostic program, 
MolDX Technical Assessment, the requested PrismRA test is not an approved test. Based on this information, 
we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we 
decided that the Plan does not have to pay for  the unlisted molecular pathology procedure (PrismRA) (81479) 
provided January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87631, 99072) provided on June 28, 2022. 
 
You asked the Plan to pay for the services. 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 (87631) 
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. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
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 testing have not 
been met. 
 
We also find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of code 99072 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (87631, 99072) provided on June 28, 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 the enrollee has stabilized and is ready 
for discharge from the acute care hospital. You also say an LTACH admission is necessary for the enrollee to 
regain maximum/prior level of functioning and to continue a multi-disciplinary approach to care. The Plan 
denied your request. The Plan says it is not medically necessary for the enrollee to be in an LTACH in place of 
an acute care 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 that all medically necessary care is being provided in the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient has failed on other devices and 
he was unable to persistently maintain pH balance. His CO2 levels raised on other devices causing respiratory 
failure. The Plan denied your request. The Plan says a home ventilator is not medically necessary because the 
patient's needs can be met with a bilevel positive airway pressure (BiPAP) device with average volume-assured 
pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee is a 70-year-old 
male with a history of morbid obesity and obesity hypoventilation syndrome (OHS). There are no additional 
pulmonary diagnoses though the pre-printed ventilator order notes restriction. The submitted pulmonary 
evaluation is limited to arterial blood gas analysis (ABG) showing hypercarbia (pH 7.35, PaCO2 62, and PaO2 
84). The provider. You did not submit any additional pulmonary information including baseline arterial blood 
gas analysis (ABG), complete pulmonary function testing (PFT), polysomnography (PSG), or oximetry. The 
member was recently admitted to acute care for congestive heart failure (CHF) and improved with appropriate 
therapies that included BiPAP with AVAPS. A request is now made for a home mechanical ventilator with 
AVAPS mode to assure adequate tidal volume ventilation. This patient does not have neuromuscular disease, 
thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
The documentation in the medical record does not support that the ventilator at issue is medically necessary 
and reasonable for this patient. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 29, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates these tests are included in the dialysis rate. 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 29, 2022.