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

 
We decided that the Plan does not have to pay for the Xpert Xpress respiratory virus genetic testing panel 
provided on December 21, 2022, billed with code 0241U. 
 
You asked the Plan to pay for the Xpert Xpress panel. You say that this should be paid.  The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the Xpert Xpress 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the Xpert Xpress 
respiratory virus genetic testing panel provided on December 21, 2022, billed with code 0241U.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET); 
metabolic evaluation (78608).  
 
You asked the Plan to pre-approve the PET scan. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is noted to have a history of 
memory problems. In this case, the medical records provided for review did not indicate that the enrollee met 
diagnostic criteria for either AD or FTD, let alone both diagnoses. In as much the baseline criteria for coverage 
of a PET/CT scan for dementia would not be met. In as much the request cannot be said to meet the Medicare 
criteria for coverage. 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 PET scan have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve a brain imaging, positron emission tomography (PET); metabolic evaluation (78608).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital facility care provided on May 19, 2022. 
 
You asked the Plan to pay for the billed services . You say that the revenue code encompasses the entire 
inpatient stay at the facility. The Plan denied your request. The Plan says a valid revenue code was not billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim was submitted with a type of bill (TOB) code 111, indicating 
inpatient care. However, revenue code 0450 was billed, indicating an emergency room level of service. 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 the hospital facility care provided on May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracorporeal photopheresis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says services related to clinical trials are covered by Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that routine costs for clinical trials are covered by Original 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that the requested services are for part of a clinical 
trial. Coverage for these services must be approved by Original Medicare, not the Plan. Therefore, we decided 
that the Plan does not have to pre-approve extracorporeal photopheresis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation oncology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve radiation oncology services. You say that this provider is closer and more 
convenient, and the Plan's recommended provider is too far away. The Plan denied your request. The Plan says 
this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider within 
an accessible time and distance from the enrollee's home. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.   
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from the enrollees home who can provide radiation oncology 
services. Under Medicare rules, this means that contract providers are accessible to the enrollee. Therefore, we 
decided that the Plan does not have to pre-approve radiation oncology services to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump 
(E2402) and supplies (A6550). 
 
You asked the Plan to pre-approve a NPWT pump and supplies. 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 follows Medicare rules. Medicare rules say that a Negative Pressure Wound Therapy pump (E2402) 
and supplies (A6550, A7000) are covered when specific 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 a NPWT pump and supplies. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found a negative pressure 
wound therapy pump (E2402) and supplies (A6550, A7000) criteria have not been met. The enrollee does not 
have a chronic Stage 3 or 4 pressure ulcer, venous or arterial insufficiency ulcer, or a chronic ulcer of mixed 
etiology with evidence of failure from conservative methods of wound management. 
 
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 NPWT pump and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump (E2402) and supplies 
(A6550).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix, per sq cm (Q4186). 
 
You asked the Plan to pre-approve wound care. You say that failure to treat with Epifix may result in the 
following complications and unnecessary cost, additional wound care visits, infection, hospitalization, 
additional surgeries, new hardware, reduced quality of life, or home health. The Plan denied your request. The 
Plan says the records do not show that the enrollee has had standard wound care for at least 30 days. The 
request 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 wound care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the review indicates that the enrollee underwent craniotomy on February 7, 2023, for removal 
of adenocarcinoma and radiation necrosis of tissue of the temporal lobe. He has a nonhealing wound of the 
surgical site. He is receiving standard wound care with weekly debridement, specialized dressing, compression 
therapy, nutrition education. On April 11, 2023, the wound measured 4.3 x 6.5 x 0.3 cm. He was noted to have 
a large amount of necrotic tissue and slough. On March 21, 2023, the wound measured 1.5 cm x 6cm x 0.3 cm. 
Records do not show that the enrollee has had standard wound care for at least 30 days. The requested item is 
not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epifix, per sq cm (Q4186).
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 
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 at the time of admission, the enrollee required skilled rehab services to improve 
function due to weakness and deconditioning. There were no skilled nursing needs. As of the last covered day, 
the enrollee did not require any skilled nursing or rehab services on a daily basis. She was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or self-care tasks. The enrollee did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an 
inpatient basis, at a skilled level of care as of February 20, 2023. The enrollee did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. The enrollees function was at or near 
her prior level of function and she could be discharged to a lower level of care for further services. As of 
February 20, 2023, the enrollee required custodial services. The denial for further inpatient skilled care beyond 
the last covered day is upheld.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is helping to support 
and sustain the enrollee's life. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show that the ordered settings for the noninvasive ventilator can be delivered by 
a bi-level PAP machine with AVAPS capability. We also did not receive any records that say the enrollee did 
not improve with BiPAP at home, or failed BiPAP with backup AVAPS. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure with a paralyzed left hemidiaphragm, pulmonary hypertension, obstructive sleep 
apnea and chronic obstructive pulmonary disease. Provided records document that the home ventilator is being 
requested for use in average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) which 
could be provided by a BiPAP device with 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. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 12, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on September 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services (99233) provided on 
November 16, 2022. 
 
You asked the Plan to pay for subsequent hospital care services. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital care services have not been met. Specifically, this claim has been billed with 
diagnosis code R65.20 as the primary diagnosis code. Diagnosis code R65.20 has a code-first note, meaning that the underlying condition must be sequenced first on the claim. Therefore, we decided that the Plan does 
not have to pay for subsequent hospital care services (99233) provided on November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (62323). 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services 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 a repeat epidural steroid injection. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case.  
Our physician reviewer found that the enrollee did not have 3 months of sustained pain improvement from the 
prior epidural injection.  
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 repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection (62323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service September 
22, 2022.  
 
You asked the Plan to pay for procedure code 88291. 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 88291 is 1. The MAI value for this code is 3. You billed 3 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 88291 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code 88291 billed for date of service September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on May 18, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that it was not possible to obtain authorization. The 
Plan denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on May 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 8, 2022, to 
June 9, 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 April 8, 2022. The NOA was not received by the Plan. 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 April 8, 
2022, to June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMems device. 
 
You asked the Plan to pre-approve a CardioMems device. You say that the requested CardioMems is medically 
necessary and beneficial to the enrollee. The Plan denied your request. The Plan says the requested device is 
considered experimental and investigational. This means there are not enough medical studies to support the 
use of this device for the enrollee's condition. 
 
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 CardioMems device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was implanted, 
reflecting an enrollee population with preserved ejection fraction and was somewhat limited in scope. 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in enrollee management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollee's clinical management. 
 
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 CardioMems device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMems device.