Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Tempus xT Solid Tumor testing (81456) provided on May 19, 2023. 
 
You asked the Plan to pay for Tempus xT Solid Tumor testing. You say that this test was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this test is not covered by 
Medicare, as this test shows no coverage through the MolDX program. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Of note, the research provided by the Plan reflects information for 
a different test which is performed/provided by a different laboratory and is not relevant to the test and 
laboratory at issue in this case. Based on this information, we decided that Medicare rules for coverage of 
Tempus xT Solid Tumor testing have been met. Therefore, we decided that the Plan has to pay for Tempus xT 
Solid Tumor testing (81456) provided on May 19, 2023.  
 
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 pre-approve a vascular embolization or occlusion (37243) and an 
ultrasound guidance for vascular access (76937). 
 
You asked the Plan to pre-approve geniculate artery embolization. You say that genicular artery embolization 
is a minimally invasive therapy that may be of significant benefit to the enrollee with reduced mortality and 
morbidity compared to alternative surgical options which the enrollee is hoping to avoid. This has been shown 
in a multi-center randomized controlled study. It is medically necessary for the enrollee. The Plan denied your 
request. The Plan says there are not enough studies on genicular artery embolization for treatment of knee 
osteoarthritis to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve geniculate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee. There is 
insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. The elements of the coverage criteria are not satisfied.  The requested service is 
not 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 geniculate artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a vascular embolization or occlusion (37243) and an ultrasound guidance 
for vascular access (76937).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the heart. 
 
You asked the Plan to pre-approve CT scan of the heart. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the medical records received did not include medical information to 
determine if the enrollee meets the medical necessity requirements above. Therefore, the requested computed 
tomographic angiography of the heart, coronary arteries, and bypass grafts (when present), with contrast 
material, is not medically necessary/not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan of the heart. Our reviewer says 
that the service is medically necessary. Our physician reviewer found there is evidence that a CT angiogram 
can detect asymptomatic significant coronary artery disease which in this case would prompt her physician to 
reinforce her current treatment for dyslipidemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the heart have been met. Therefore, we decided that the Plan has to 
pre-approve CT scan of the heart.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0453, 95908, and 95940-59 billed for date 
of service February 27, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
services are not supported. 
 
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 G0453 is a column II code to column I code 95940; and code 95908 
is a column II code to column I code 95861. Column II codes G0453 and 95908 have not been billed with an 
appropriate modifier to bypass the edit. Based on this information, we decided that Medicare rules for coverage 
of the billed services have not been met. 
 
We find that code 95940-59 is not supported. There are no code edits for this code and any other code billed on 
the claim at issue. The medical records do not show that the service billed with the -59 modifier was a distinct 
procedural service. 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 procedure codes 
G0453, 95908, and 95940-59 billed for date of service February 27, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. This enrollees condition is in fact sufficiently complex, 
and there is every reason to expect that they will participate in and benefit from IRF-level services to include at 
minimum PT, OT, physician oversight of wound care, polypharmacy, and case manager coordination of any 
additional services that might be needed to make a sustainable return home. It is highly unlikely that the 
enrollee's needs could be met at a lower level of care. Therefore, the requested IRF admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item is medically necessary. 
The Plan denied your request. The Plan says this item is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that a discharge with home health services is not safe for 
the enrollee and more rehabilitation is required. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 that 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 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 SNF care.
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 needs physical therapy services and is 
too weak to return home at this time. The Plan denied your request. The Plan says the enrollee does not meet 
the 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 there are no acute rehab nursing needs documented. At the current functional level, 
the enrollee does not need 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 medical, rehab, 
and nursing needs does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. The enrollee's rehab needs can be safely provided in an alternate and low intensity setting 
such as in a skilled nursing facility or in-home with services.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 requires an IRF level of care. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is in fact complex and fragile and there is every reason to expect that the enrollee 
will participate in and benefit from an IRF level of services to include at minimum PT, OT, RT, physician 
oversight of polypharmacy, and case manager coordination of any additional services that might be needed to 
make a sustainable return home as well as avoid preventable readmissions to the acute hospital. Therefore, the 
requested inpatient rehab facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 8, 2023, billed with 
evaluation and management (EM) code 99214-25. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this service is bundled into payment of the primary 
procedure. 
 
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 99214-25 is a column II code to column I code 51703; however, 
99214-25 was billed with a modifier.  
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the procedure report does not include 
sufficient documentation to support significant, separately identifiable evaluation and management service was 
provided.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 8, 2023, billed with evaluation and 
management (EM) code 99214-25.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 87635 billed for date of service 
May 24, 2023. 
 
You asked the Plan to pay for two units of procedure code 87635. You say that these services were necessary 
and were reported appropriately. The Plan denied your request. The Plan says this service is not supported for 
the number of units 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 87635 is infectious agent detection by nucleic acid (DNA 
or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), 
amplified probe technique. 
 
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 two units of procedure code 87635. Our reviewer says that 
this code is not supported in the medical record. Our reviewer found the elements that were tested are not 
within the criteria that supports code 87635. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two units of procedure code 87635 have not been met. Therefore, we decided 
that the Plan does not have to pay for two units of procedure code 87635 billed for date of service May 24, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this item is medically necessary 
because your hospice is picking up your current bed. The Plan denied your request. The Plan says this item is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 skilled nursing visits, 12 physical therapy visits and 3 
occupational therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled nursing needs. Our reviewer also found that the enrollee does not 
have documented skilled therapy needs.  As such, the requested home health services are not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 skilled nursing visits, 12 physical therapy visits and 3 occupational therapy 
visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 29 miles for a total of 79 miles one-way 
trip. 
 
You asked the Plan to pre-approve the additional 29 miles. You say that the services are medically necessary 
for your kidney appointment. The Plan denied your request. The Plan says your request exceeds your benefit 
limit.  
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 29 miles for a total of 79 miles one-way trip.
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 be able to tolerate daily 
therapy and improve in a short amount of time to be able to return home safely with family at prior level of 
function. The Plan denied your request. The Plan says the enrollee does not meet the 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 there are no acute rehab nursing needs documented. At the current functional level, 
the enrollee needs physical and occupational therapy services. Document does not support necessity for 
admission to an IRF. The complexity of the enrollees medical, rehab, and nursing needs does not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollees rehab 
needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
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.