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

 
We decided that the Plan does not have to pre-approve Transcatheter Aortic Valve Replacement (TAVR). 
 
You asked the Plan to pre-approve TAVR. 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 transcatheter aortic valve replacement (TAVR - also 
known as TAVI or transcatheter aortic valve implantation) is used in the treatment of aortic stenosis. 
 
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 TAVR. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the most recent echocardiogram showed 
significant aortic regurgitation, rather than aortic stenosis. Guidelines would not support aortic valve 
replacement based on the submitted medical records. As a result, at this time the requested TAVR would not be 
considered medically necessary in this enrollee's clinical management based on the submitted 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 TAVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Transcatheter Aortic Valve Replacement (TAVR).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on September 6, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was not 
billed with the appropriate test identifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the claim was not billed with the appropriate test identifier. 
However, the submitted claim form was billed with DEX Z-code Z00D5. The Plan has not provided 
documentation showing that this code is inappropriate for the billed testing. Without supporting documentation, 
the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the genetic testing 
provided on September 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee 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 enrollee does not require treatment by multiple therapies. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with 
severe airways obstruction and air trapping, as confirmed on pulmonary function testing. However, there is no 
ABG, done while stable, to document chronic CO2 retention. If that is present, the enrollee may benefit from 
BiPAP with AVAPS during sleep as an outpatient. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. 
 
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 (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in VAPS mode with Auto-
EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 the service is not medically necessary. Our physician reviewer found you have COPD, OSA intolerant of 
CPAP, and valvular heart disease. You were recently hospitalized and suffered acute on chronic hypercarbic 
respiratory failure, but it is unclear how much this was due to COPD versus acute on chronic heart failure. 
There were bilateral pleural effusions requiring thoracentesis. There is no ABG done while stable to document 
chronic CO2 retention. If that is present, you may benefit from BiPAP with AVAPS during sleep as an 
outpatient. That has not been tried and failed as an outpatient. Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. 
 
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 (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99406 billed for date of service June 15, 
2022. 
 You asked the Plan to pay for procedure code 99406. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says payment for code 99406 is bundled into 
payment for code 90792. 
 
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, we have confirmed that code 99406 
is a column II code to column I code 90792. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99406 billed for date of service June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 Reader and sensors. 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM). You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor (CGM). 
Our physician reviewer found the review has determined that you do not have diabetes mellitus. You are not 
insulin treated with three or more daily administrations of insulin or a Medicare-covered continuous 
subcutaneous insulin infusion pump. Your insulin treatment regimen does not require frequent adjustment by 
the beneficiary on the basis of blood glucose meters (BGM) or CGM testing result. 
 
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 continuous glucose monitor (CGM) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Freestyle Libre 2 Reader and sensors.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal diagnostic testing (code 81479) provided 
on October 17, 2022. 
 
You asked the Plan to pay for Guardant Reveal. You say that you are the only provider for this test. 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 shows that the required unique identifier has 
been reported on the claim. However, the DEX Registry shows this test has a coverage status of not covered. 
Based on this information, we decided that Medicare rules for coverage of Guardant Reveal have not been met. 
Therefore, we decided that the Plan does not have to pay for Guardant Reveal diagnostic testing (code 81479) 
provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0269 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code G0269. The Plan denied your request. The Plan says procedure 
code G0269 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 G0269 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code G0269 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0269 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0269 billed for date of service July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
August 4, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documented history on 
August 4, 2022 described the enrollee has having shortness of breath and palpitations. The physical 
examination was focused and showed rales, and normal heart rate and sound. The chest x-ray showed a 
pulmonary edema. The enrollee was treated with diltiazem, Lasix, low dose oxygen support only, and 
monitoring and was otherwise stable. Acute coronary syndrome (ACS) was ruled out. The records do not 
sufficiently support a comprehensive history or physical, nor was there support for medical decision-making of 
high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1852) provided on October 11, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says knee instability is not documented by examination of the beneficiary. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there has not been any recent injury or surgery to the knees. The documentation does not support 
that the current left knee symptomatology is not an ongoing and/or chronic problem. The provided report does 
state that she has a diagnosis of instability of the left knee. However, the objective findings simply state No 
change since last visit. The last visit was not provided to corroborate those unchanged findings or to support 
objective findings of instability. Therefore, knee instability is not documented on the exam that has been 
provided. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1852) provided on October 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
14, 2022, to September 30, 2022. 
 You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says ongoing skilled care could have been provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not qualify for SNF coverage. The enrollee did not have documented 
skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs were custodial and could, as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from September 14, 2022, to September 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from February 1, 2022, to February 26, 
2022. 
 
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 it is inappropriate billing to use revenue code 
0636 with HCPCS code J0604.  
 Review of the file shows that the claim was billed with code J0604, revenue code 0636, and a unit of 90 per 
date of service. The MLN specifically states, beginning January 1, 2021, the cinacalcet oral drug is eligible for 
consideration as an ESRD outlier service: Report the number of tablets or pills, not the number of units (for 
example, milligrams); Report revenue code 250 with the national drug code; Do not use revenue code 0636 
with HCPCS code J0604. Therefore, since the claim was billed incorrectly it cannot be processed. Please 
contact the Plan in regard to submitting a corrected claim. Therefore, we decided that the Plan does not have to 
pay for the services provided from February 1, 2022, to February 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307 and 83789) provided on 
December 8, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. In addition, codes G0480 
and 80307 are not supported by the medical records provided. 
 The Plan must follow Medicare rules. The rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. Medicare rules also say that providers performing validity 
testing on urine specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. In addition, we find that the medical records do not support codes 80307 or G0480. In this 
case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug classes, 
any number of devices or procedures; by instrument chemistry analyzers, includes sample validation when 
performed, per date of service. However, the records provided do not include results for any presumptive drug 
screening tests. Therefore, this service cannot be verified. The CPT Code Manual definition of code G0480 is 
drug test(s), definitive, 1-7 drug class(es), including metabolite(s) if performed. However, the records indicate 
that drugs from more than 7 classes were tested in this case, which means another code would report the 
service provided more accurately. Therefore, we decided that the Plan does not have to pay for drug testing 
services (G0480, 80307 and 83789) provided on December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis, not otherwise specified 
(L5999). 
 
You asked the Plan to pre-approve a lower extremity prosthesis. You say that the enrollee needs a new socket 
due to weight gain. The Plan denied your request. The Plan says the requested prosthetic does not meet 
Medicare or health plan coverage criteria. 
 
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. Medicare rules confirm that L5999 must not be used to bill for any 
features or functions included in the socket or addition codes. Based on this information, we decided that 
Medicare rules for coverage of a lower extremity prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lower extremity prosthesis, not otherwise specified (L5999).