Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) 
surgery (Watchman procedure). 
 
You asked the Plan to pre-approve Watchman procedure. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the records show the enrollee has not had a formal shared decision-making interaction with an independent non-interventional physician using an evidence-based 
decision tool on oral anticoagulation. 
 
The Plan follows Medicare rules. Medicare rules state that LAAC procedures such as the Watchman procedure 
are only covered through the Coverage with Evidence Development (CED) program when certain criteria 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 Watchman procedure. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found while the record 
includes reference to consideration of the LAAC, there is no documentation of performance of an evidence-
based shared decision-making interaction on anticoagulation. As such, guidelines would not support 
implantation of a LAAC device in this 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 Watchman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous left atrial appendage closure (LAAC) surgery (Watchman 
procedure).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 22, 2022, to 
April 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 22, 2022, to April 
18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TissueCypher barrett's esophagus assay (0108U) provided on 
August 16, 2022. 
 
You asked the Plan to pay for TissueCypher barrett's esophagus assay. You say that this test was medically 
necessary and is covered by Medicare. The Plan denied your request. The Plan says this test does not meet the 
criteria for medical necessity. 
 
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 TissueCypher barrett's esophagus assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found although data regarding this modality has been presented at societal 
meetings, no gastrointestinal society has recognized this technique as standard of care. It is promising, but at 
this time it is not considered medically necessary for patients such as the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TissueCypher barrett's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for TissueCypher barrett's esophagus assay (0108U) provided on 
August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires close supervision as they are 
unbale to care for themselves without assistance. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met in another setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 10, 
2022, to September 22, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient hospital admission was 
medically necessary. The Plan denied your request. The Plan says an admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was stable and was held pending placement without evidence of invasive 
treatment or instability to suggest a need for inpatient services that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided September 10, 2022, to September 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and bilateral 
leg sleeves (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and bilateral leg sleeves. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
bilateral leg sleeves. Our reviewer says that the items are not medically necessary. Our physician reviewer 
found the beneficiary does not have persistence of chronic and severe lymphedema as identified by the 
documented presence of at least one of the following clinical findings: Marked hyperkeratosis with hyperplasia 
and hyperpigmentation, Papillomatosis cutis lymphostatica, Deformity of elephantiasis, Skin breakdown with 
persisting lymphorrhea, Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology. In addition, the lymphedema was not documented to be 
unresponsive to other clinical treatment over the course of a required four-week trial. 
 
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 pneumatic compression device and bilateral leg sleeves have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and 
bilateral leg sleeves (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
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 are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's 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 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. 
 
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 pay for a medical alert necklace purchased on April 26, 2022. 
 
You asked the Plan to pay for a medical alert necklace. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Telephone Alert Systems are not covered 
because emergency communications systems do not serve a diagnostic or therapeutic purpose.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a medical alert necklace have not been met. Therefore, we decided that the Plan does not have to 
pay for a medical alert necklace purchased on April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 17, 2023, to 
January 19, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary The Plan denied your request. The Plan says that the inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 17, 2023, to January 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 sacroiliac joint fusion. 
 
You asked the Plan to pre-approve sacroiliac joint fusion. 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 sacroiliac joint fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested sacroiliac joint fusion, in 
this case, is not medically reasonable or 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 sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 
18, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761, and 99072 billed for date of 
service August 2, 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 services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported for code 87631. Based on this information, we decided that Medicare rules for coverage 
have not been met. 
 
We 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 have not been met. 
 
We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. Code 94761 was 
billed on the same day as another payable service, which means it is not separately payable. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87631, 94761, and 99072 billed for date of service August 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 30, 
2022, to January 1, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the intensity of service does not meet acute 
inpatient level of care. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found while the enrollee appears to have arrived in the emergency department on the 
evening of December 30, 2022, documentation notes that provider care did not start until December 31, 2022, 
at 0606. The enrollee was then placed in observation status, stayed one midnight, and was converted to 
inpatient status immediately before discharge on January 1, 2023. The documentation does not show that two 
midnights of care were provided, that two midnights of care were expected following the evaluation, or that 
two midnights of care were expected at the time of admission. The hospitalization appears to have been 
precautionary and able to be completed at an observation 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided December 30, 2022, to January 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99490) provided on July 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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, the CPT Code Manual definition of code 99490 is "Chronic care management services with the 
following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or 
until the death of the patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health 
care professional, per calendar month". 
 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 use of code 99490 is 
not supported by the records provided. Our reviewer found that the records do not document how the enrollee's 
essential hypertension and gastro-esophageal reflux disease without esophagitis are conditions that place the 
enrollee at significant risk of death, acute exacerbation/decompensation, or functional decline. 
 
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 the services (99490) provided on July 21, 2022.