Persius/hicric huggingface dataset:
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 these services are 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 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 presently receiving appropriate services in the acute care setting. 
Records do not support the need to transfer from one acute hospital to another. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that this service is necessary for the enrollee. The Plan 
denied your request. The Plan says that Medicare and Plan criteria for coverage are not 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that routine use of SBRT for palliation of spine metastases in the setting of more widespread 
disease is not in accordance with accepted standards of medical practice. The case file does not demonstrate 
necessity which would be needed when the treatment is not standard of care for routine practice. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. 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 Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Granix. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not document that the 
neutropenia is the setting of chemotherapy for a non-myeloid malignancy. The Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 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 Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive inpatient rehabilitation 
with daily physician management, continuous specialized rehabilitation nursing, and intensive therapies to 
optimize mobility and strength while ensuring the restoration of functional status for a safe and sustainable 
discharge. The Plan denied your request. The Plan says  the enrollee does not meet all the requirements 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 the 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 an IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 6, 2022, to 
September 4, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 6, 2022. The NOA was not received by the Plan until November 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from August 6, 2022, to September 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 22, 2022, to 
October 31, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 22, 2022. The NOA was not received by the Plan until January 5, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from October 22, 2022, to October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (96365, 96366, 96521) provided on 
February 9, 2023. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance 
of portable pump. 
 
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 medical services. Our reviewer found the codes in 
question are not supported by the medical record. The record states that a continuous insulin infusion was 
performed with guidance by glucose measurements. According to Current Procedural Terminology (CPT) 
rules, there is a more specific code to report this procedure. The codes are not coded to the highest level of 
specificity. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services (96365, 96366, 96521) provided on February 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Guardant Reveal testing (81479) provided on 
February 17, 2023. 
 
You asked the Plan to pre-approve the service. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient data to recommend post-surgical ctDNA to estimate risk of recurrence or 
determine adjuvant therapy. The review has determined that the requested Guardant Reveal testing at issue 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Guardant Reveal testing (81479) provided on February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee, advanced foot 
feature, and an expandable wall socket (L5653, L5828, L5845, L5856, L5981). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show why the enrollee's current foot and knee, which are intact and 
have not been used for three years, will not meet the enrollee's needs. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not contain sufficient documentation to support a functional need for all of the 
requested microprocessor knee and foot. The plan's denial is valid. There is no evidence that the enrollee has 
irreparable damage to the current knee and foot or why the current knee and foot cannot be utilized with the 
new socket. The expandable wall socket exceeds the enrollee's needs as the prosthesis already comes with a 
flexible inner socket and this request would be duplicative. The documentation does not fully support the 
enrollee is a K3 ambulator as she is stated to not have worn her prosthesis in three years. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an electronic knee, advanced foot feature, and an expandable wall 
socket (L5653, L5828, L5845, L5856, L5981).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the soft tissue neck (70491). 
 
You asked the Plan to pre-approve a CT scan of the neck. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
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 a CT scan of the neck. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the request for a surveillance CT 
of the neck now is reasonable and due to the findings at pathology the request is appropriate. 
 
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 CT scan of the neck have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography (CT) scan of the soft tissue neck (70491).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71271 billed for date of service March 1, 
2023.  
 
You asked the Plan to pay for procedure code 71271. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 71271 is bundled into payment for code 71250. 
 
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 71271 is a column II code to column I code 71250 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 code 71271 billed for date of service March 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 7055 billed for date of service November 3, 
2022. 
 You asked the Plan to pay for procedure code 7055. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 7055 is bundled into payment for code 70546. 
 
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 7055 
is a column II code to column I code 70546. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 7055 billed for date of service November 3, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 2, 
2022, through November 4, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee did not want to be 
discharged on November 3, 2022. The Plan denied your request. The Plan says observation services would 
have been more appropriate.  
 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 based on the low severity and complexity of the presentation and workup findings, it 
was not expected that the enrollee would have required hospital services that would have likely crossed 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 from November 2, 2022, through 
November 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service May 3, 2023.  
 
You asked the Plan to pay for procedure code 76641. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim should be paid. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is one (1). The MAI value for this code is 2. You billed two (2) 
units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage 
of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81518 billed for date of service March 24, 
2023. 
 
You asked the Plan to pay for procedure code 81518. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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 81518 is: Oncology (breast), mRNA, gene expression 
profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-
embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit 
from extended endocrine therapy. 
 We find that CPT code 81518 is not supported in the medical record. Specifically, the provided record does not 
indicate the genes profiled. Code 81518 cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of procedure code 81518 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81518 billed for date of service March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid billed with code V5261 for January 24, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the hearing aid. 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 hearing aid billed with code V5261 for January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4623, A7526, and A4629 billed for 
February 7, 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 there is no itemized shipping invoice. 
 The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid itemized shipping invoice to 
support the services as rendered. Therefore, we decided that the Plan does not have to pay for procedure codes 
A4623, A7526, and A4629 billed for February 7, 2023.