Persius/hicric huggingface dataset:
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 enrollee has severe obesity 
hypoventilation syndrome with associated chronic hypercapnic respiratory failure that has resulted in 
multifactorial pulmonary hypertension as well. Without NIV therapy, this enrollee is at high risk for hospital 
readmission and potentially life-threatening exacerbation. 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 obesity, 
obesity hypoventilation syndrome, aortic stenosis, HFpEF, and pulmonary hypertension. The enrollee was 
hospitalized in January and again in April of this year. Arterial blood gases were consistent with acute on 
chronic hypercarbic respiratory failure. In April, the enrollee failed BiPAP and AVAPS in the hospital and 
required intubation. There is no documentation of failure of BiPAP with AVAPS as an outpatient. There is no 
diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease.  Medicare does not cover a home 
ventilator for the treatment of obesity hypoventilation syndrome or heart disease, or 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided superficial radiotherapy.  
 
You asked the Plan to pre-approve image guided superficial radiotherapy. You say that image guided 
superficial radiotherapy is medically necessary. The Plan denied your request. The Plan says image guided 
superficial radiotherapy 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 image guided superficial radiotherapy. 
Our reviewer says that the requested image guided superficial radiotherapy is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that image guided superficial radiotherapy 
is not medically necessary for this type of skin cancer and anatomical location. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image guided superficial radiotherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve image guided superficial radiotherapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service August 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder arthroplasty (29826) provided on November 29, 
2022. 
 
You asked the Plan to pay for the shoulder arthroplasty. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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 CPT Code Manual definition of code 29826 is arthroscopy, shoulder surgical; decompression 
of subacromial space with partial acromioplasty, with coracoacromial ligament release. 
 
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 shoulder arthroplasty. Our reviewer says that the billed code is not supported in the records. Our reviewer found the procedure report includes insufficient 
documentation to confirm a decompression of subacromial space with partital acromioplasty, with 
corocoacromial ligament was performed. 
 
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 shoulder arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pay for a shoulder arthroplasty (29826) provided on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (sit-to-stand lift, E0637).  
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a seat lift mechanism. Our reviewer 
says that the enrollee does not need this item. Our physician reviewer found the documentation does not support that the seat lift will arrest or retard the patient's condition and it is not clear in the notes whether the 
patient is completely incapable of standing from a chair in the home. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (sit-to-stand lift, E0637).
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 enrollee is an 84 -year-old appealing the denial of an IRF admission. Record 
reviewed. The enrollee was admitted to an acute hospital on May 22, 2023, after a fall sustaining left hip 
fracture. Underwent ORIF and post-op received PRBC transfusion for anemia. Medically stable with debility. 
PMH: HTN, HLD, Hypothyroidism, DM, ESRD on PD, and anemia. Referred to an IRF for admission on May 
26, 2023, with an ELOS of 11 days. Lives alone. PLOF: Independent. Therapy notes reviewed. On review of 
the available records, the enrollee with history as described above does not meet CMS coverage criteria for IRF 
admission. The enrollee is medically stable and does not need PMR physician's supervision 3 times a week in 
an IRF. No medical complexity. No acute rehab nursing needs identified or documented. The enrollee does not 
need specialized and intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach in an IRF. Document does not support necessity for admission to an IRF. 
The complexity of the enrollee's nursing, rehab, and medical, needs (combined complexity) does not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. An uncomplicated 
hip fracture patient does not need an IRF admission. While the enrollee may benefit from physical therapy, and 
occupational therapy, the enrollee's rehab needs can be provided in a lower intensity and alternate setting such 
as in an SNF.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant extraction (D6100), guided tissue regeneration 
(D4266) and bone replacement graft (D7953) provided on March 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary and are related to 
or similar to services which are covered by your dental benefit. The Plan denied your request. The Plan says 
these services are not covered by your benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant extraction (D6100), guided tissue regeneration (D4266) and bone replacement graft (D7953) provided 
on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service April 16, 2022. 
 
You asked the Plan to pay for code 99223. You say that the history and exam were comprehensive in nature 
which meets the requirements of the billed code. The Plan denied your request. The Plan says code 99223 is 
not supported by the medical records. The medical records provided do not support a comprehensive history. 
 
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 three key components: a comprehensive history, 
a comprehensive exam, and medical decision making of high complexity. 
 
 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 code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found the enrollee was a then, 74 yo female with a history of 
coronary artery disease, status post coronary artery bypass graft (CABG), cardiomyopathy femoral popliteal 
bypass who was admitted form a rehab facility with shortness of breath and question of pneumonia. For the 
date of services April 16, 2022, Current Procedural Terminology (CPT) code 99223-25, AI (1 Unit) was not 
supported. This initial hospital care evaluation and management code requires a comprehensive history, a 
comprehensive examination and medical decision making of high complexity. In this case, the medical records 
submitted did not support a comprehensive history. The review has determined that the documentation did not 
support code 99223. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service April 16, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve oncology (solid organ neoplasm), targeted genomic sequence 
DNA analysis of 505 genes (0250U). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that the requested laboratory assay test intended 
for personal genome diagnostics does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case.   Our physician 
reviewer found information provided to this reviewer indicate the test has been approved through the MoIDX 
Technical Assessment, and the records show the enrollee's cancer is recurrent with an intention to proceed with 
further treatment with no prior testing of the tumor by the same test for the same genetic content. Thus, 
according to the rules in the Local Coverage Determination (LCD) MolDX: Next-Generation Sequencing for 
Solid Tumors L38045, coverage criteria for the test have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes (0250U).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that the claim should be reviewed and processed 
for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
  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 S9200 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9200 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87507 for date of service January 18, 2023. 
 
You asked the Plan to pay for procedure code 87507. You say that you disagree with the Plan's denial. 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 procedure code 87507 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87507 for date 
of service January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87631 billed for date of service January 19, 2023. 
 
You asked the Plan to pay for code 87631. You say that you have provided medical records to support 
payment. 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 code 87631 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 87631 billed for date of service 
January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 sensors.  
You asked the Plan to pre-approve the Dexcom G6 sensors.. You say that your doctor requested this and if you 
are not able to get it your life will be at risk. The Plan denied your request. The Plan says you do not use insulin 
to treat your diabetes. 
 
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 Dexcom G6 sensors. Our reviewer 
says that the continuous glucose monitor coverage requires insulin use or level 2 hypoglycemia and the records 
do not show either of these are present so coverage criteria has not been met. Our physician reviewer found the 
request for the CGM is not 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 Dexcom G6 sensors. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Dexcom G6 sensors.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is expected to make functional gains and 
continue with return to home goals. The Plan denied your request. The Plan says the enrollee's records do not 
show that your rehab needs are complex and that you need to be seen 3 times per week for evaluation of 
functional and medical goals and progress. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.