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

 
We decided that the Plan does not have to pay for WATS 3D (88361, 88312, 88305, 88112) provide September 
1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that your laboratory received an esophageal 
biopsy specimen that was obtained on September 1, 2022, during an esophagogastroduodenoscopy performed 
on the enrollee by the specialist. The Plan denied your request. The Plan says this service does not meet the 
medically necessary requirements. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee with Barrett's esophagus who underwent an esophageal biopsy on 
September 1, 2022, during an esophagogastroduodenoscopy performed by the specialist. However, WATS 3D 
has not yet been supported by independent high quality studies showing benefit in terms of mortality and 
morbidity compared to standard biopsy methods to date and current guidelines stance as not recommending the 
test also reflects this missing evidence. Therefore, this request for WATS 3D will be considered not medically 
necessary at this time.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for WATS 3D (88361, 88312, 88305, 88112) provide September 1, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you have no one at home to assist you with daily 
living. The Plan denied your request. The Plan says that the SNF services you are requesting do not meet the 
requirements for approval. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do have skilled therapy needs that require the specialized skill, knowledge, and 
judgement of a qualified therapist. You do require skilled therapy on a daily basis. You do require skilled 
services on an inpatient basis in a SNF setting. The services are reasonable and necessary for the treatment of 
your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xT testing (81455) provided on February 9, 2023.  
 
You asked the Plan to pay for the Tempus xT testing. You say that the referring provided regarded this as 
medically necessary and a valuable tool when determining treatment for the enrollee. The Plan denied your 
request. The Plan says that under Medicare guidelines, your request is not medically necessary because you do 
not have recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer.  
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for the Tempus xT testing. Our reviewer says 
that this service was medically necessary. Our physician reviewer found that per the National Comprehensive 
Cancer Network (NCCN) Guidelines Version 3.2023 Non-Small Cell Lung Cancer PDL1 and EGFR should be 
checked for stage II tumors to see if eligible for immunotherapy or osimertnib. Most would use a full molecular 
panel for testing such as with Tempus. The service was reasonable and 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 Tempus xT testing have been met. Therefore, we decided that the Plan has 
to pay for the Tempus xT testing (81455) provided on February 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. Provided records document that the home ventilator is being requested for use in a volume 
assured pressure support (IVAPS) mode which is a modality that could be provided by a bilevel positive airway 
pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. Therefore, the 
enrollee does not meet criteria for the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate for bone grafting (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the enrollee has instability in their 
spine and paralysis. The Plan denied your request. The Plan says this product has not been proven to be better 
than standard allograft products. 
 
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 the bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is considered experimental and investigational. Therefore, the 
requested bone marrow aspirate 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 the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone marrow aspirate for bone grafting (20939).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 6, 
2023. 
 You asked the Plan to pay for procedure code(s) 88305. You say that this service was necessary and was 
reported appropriately. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 6, 
2023.
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 the enrollee needs to continue SNF care to reach 
maximum function. The Plan denied your request. The Plan says the SNF services you are requesting do not 
meet the requirements for approval. 
 
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 require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services 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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting admission to an 
LTACH so you can get stronger. The Plan denied your request. The Plan says admission to an LTACH is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are receiving appropriate care in the current acute care setting as provided by the 
Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for thoracolumbar spine surgery. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. 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. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 still require extensive hands-on assistance from 
the nursing and therapy staff at the hospital to get out of bed, and your physician says you will need closer 
medical management of your current medical needs and disease. The Plan denied your request. The Plan says 
criteria for admission to the acute IRF setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will need another 3-4 weeks 
to continue weaning off the ventilator and to transition from his acute illness. The Plan denied your request. 
The Plan says the LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The health plan has approved ongoing 
care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Surgigraft (Q4183). 
 
You asked the Plan to pre-approve the Surgigraft. You say that this skin substitute has been shown by prior use 
of to heal this type of wound faster than conventional therapy alone. You also say that this is medically 
necessary for the enrollee due to their history of amputation. The Plan denied your request. The Plan says the 
records show that your wound has improved. The Plan also says that the records indicate you are currently 
being treated with another skin substitute. 
 
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 the Surgigraft. Our reviewer says that 
the requested Surgigraft is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records did not clearly show that the wound has not improved with treatment. The reviewer also found that there was no justification made for using more than one skin substitute at the same 
time. Therefore, the reviewer found that the request for Surgigraft 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 the Surgigraft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Surgigraft (Q4183).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 22, 
2023. 
  You asked the Plan to pay for procedure code 99100. You say that the enrollee chose an in-network surgeon 
and facility and should not be penalized for an out of network anesthesia provider. You say that this service is 
covered under the authorization and the claim should be paid at the in-network rate. The Plan denied your 
request. The Plan says procedure code 00732 has been paid and procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 22, 2023.