Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845) (which is a part of this enrollee's approved prosthesis). 
 
You asked the Plan to pre-approve the item. You say that this code is part of the total knee reimbursement 
codes. The Plan denied your request. The Plan says this part is unbundled from the approved knee and cannot 
be requested separately. The Plan states code L5814 is never paired with L5845, and this is consistent with the 
fact that stance phase feature is already included with code L5814: L5814, Addition, Endoskeletal Knee-Shin 
System, Polycentric, Hydraulic Swing Phase Control, mechanical stance phase lock L5845 cannot be used for 
this device and is unbundled. The Plan states that although the vendor uses code L5845 for this knee, neither 
the manufacturer nor the vendor have the authority to assign this code to the requested knee. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The prosthetic part requested is already included with the approved knee. This cannot be requested separately. 
That is why this requested prosthetic part is still denied. Based on this information, we decided that Medicare 
rules for coverage of the item have not been met.  Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal, knee-shin system, 
stance flexion feature, adjustable (L5845) (which is a part of this enrollee's approved prosthesis).
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 have not been well for the last 6 months and need to 
go to a SNF. The Plan denied your request. The Plan says the Skilled Nursing Facility (SNF) services requested 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 pay for procedure code Q5106 billed for date of service December 7, 
2022, to December 21, 2022.  
 
You asked the Plan to pay for procedure code Q5106. You say that you have billed the drug at issue correctly. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code Q5106 is 60. The MAI value for this code is 3. You billed 80 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code Q5106 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code Q5106 billed for date of service December 7, 2022, to December 
21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 10, 2023, billed with 
codes 87471, 87481, 87500, 87551, 87640-59, 87641, 87651, 87653 and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 10, 2023, billed with codes 87471, 87481, 87500, 87551, 87640-59, 87641, 87651, 87653 and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 3 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 3 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator for 3 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records document 
that the home ventilator is being requested for use in a pressure support 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. 
 
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 for 3 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 3 months (E0466).
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 an admission into a long term acute care 
hospital is medically necessary. The Plan denied your request. The Plan says an admission into a long term 
acute care hospital 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 the enrollee is receiving appropriate care in the current acute care setting as provided 
by Health Plan, and 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 long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the wound could get worse without 
professional care being provided. Youi state that you will need medical supplies to keep the wound clean and 
that you are unable to provide proper care. 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 the wound is 
healing, and the caregiver is providing the care. Continued monitoring from skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health 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 these services are medically necessary. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided safely in other settings. 
 
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's rehabilitation needs can be safely provided in an alternate and low 
intensity 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 the enrollee 
does not have documented home health physical therapy needs. There is no evidence of a new or worsening 
decline in function. There is no physical therapy assessment. 
 
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 home health physical therapy.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve continued use of a non-invasive ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve continued use of a NIV. You say that you are requesting reconsideration 
because the ventilator is needed. The Plan denied your request. The Plan says that the request for continued use 
of a NIV 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 continued use of a NIV. Our reviewer 
says that the service is medically necessary. Our physician reviewer found you have obesity hypoventilation 
syndrome (OHS)/obstructive sleep apnea (OSA) and chronic respiratory failure in the setting of congestive 
heart failure (CHF). You have failed inpatient BiPAP and required higher pressure support, hence, was 
prescribed and treated with a home trilogy ventilator. To withdraw therapy that you have had and step down to 
BiPAP is not standard of care or best practice. The documentation does support the medical necessity and 
rationale for a ventilator. You should continue on your Trilogy ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a NIV have been met. Therefore, we decided that the Plan has 
to pre-approve continued use of a non-invasive ventilator (NIV) (E0466).  
 
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 initial hospital inpatient or observation care provided on 
February 20, 2023. 
 
You asked the Plan to pay for initial hospital inpatient or observation care. You say that the services were 
medically necessary. The Plan denied your request. The Plan says we have insufficient documentation to 
corroborate the services so we can confirm Medicare coverage has been met.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of initial hospital inpatient or observation 
care have been met. Therefore, we decided that the Plan does not have to pay for initial hospital inpatient or 
observation care provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve the expandable controller, harness, and electronic connection. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the items are 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 the expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has adequate upper body strength to control 
the power wheelchair through its standard power drives.  
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 expandable controller, harness, and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377), 
harness (E2313), and electronic connection (E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93976 and 76705 billed for date of service 
March 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were on a different area. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied.  
 
 We looked at the file and Medicare rules. The file shows that code 93976 was reimbursed by the Plan on March 
30, 2023. A comparison of claim lines shows that these are exact duplicates. There is no evidence presented to 
support that the billed code was provided twice on the same date. Based on this information, we decided that 
the Medicare rules for the billed services have not been met. 
 
The file shows that 2 units of code 76705 was billed. The records show that 1 unit of code 76705 was paid by 
the Plan on March 30, 2023. The file also shows that on June 30, 2023, the Plan agreed to pay for an additional 
unit of code 76705. We did not find any reason which would require the Plan to pay for additional units of code 
76705. Therefore, we decided that the Plan does not have to further pay for procedure codes 93976 and 76705 
billed for date of service March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a Barostim Neo System (0266T, 
C1825). 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that the enrollee continues to have severe 
LV dysfunction. You say that the enrollee is not making much progress in terms of heart failure symptoms or 
over function. You also say that the enrollee is an excellent candidate for the Barostim. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Barostim Neo System in the setting of 
congestive heart failure have not been demonstrated in the peer-reviewed literature. 
 
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 a Barostim Neo device. Our reviewer 
says that the requested Barostim Neo device is not considered medically reasonable and necessary in this case. Our physician reviewer found there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, the 
reviewer found that the requested Barostim Neo device is not be medically reasonable and 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 a Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the implantation of a Barostim Neo System (0266T, C1825).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81455 and G0452 billed for February 3, 
2023. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 81455 is not supported and G0452 is not separately paid. 
 
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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, there are no records for this 
testing for the billed date of service. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met.  
 
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 G0452 
is a column II code to column I code 81455. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 81455 and G0452 billed for 
February 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory surgical center (ASC) services rendered on 
March 14, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that ASC claims must be billed on the ASC X12 837 
professional claim format or on Form CMS-1500 and is paid the ASC payment amount. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed on the required ASC X12 
837 or Form CMS-1500. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulatory 
surgical center (ASC) services rendered on March 14, 2023.