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 the enrollee requires daily therapy and 
physician services for a successful outcome. The Plan denied your request. The Plan says the enrollee can 
safely receive the care needed in the current hospital. 
 
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 appears to be improving gradually but is not yet stable and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. Completion of treatment at the current facility is 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the services provided on October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP). 
 
You asked the Plan to pre-approve CPAP. 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 follows Medicare rules. Medicare rules say that CPAP is covered when the documentation supports 
that the enrollee has adherence to therapy which is the use of PAP greater than or equal to 4 hours per night on 
70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial 
usage. 
 
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 CPAP. Our reviewer says that the 
documentation does not support that the enrollee meets criteria for the requested device. Our physician 
reviewer found the enrollee has sleep apnea. The record provided does not indicate that the enrollee has used 
the requested device greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) 
day period. The elements of the coverage criteria are not satisfied. 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 CPAP have not been met. Therefore, we decided that the Plan does not have to 
pre-approve continuous positive airway pressure (CPAP).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder x-ray (73030-26) and the neck x-ray (72050-26) 
provided on September 23, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the enrollee had multiple exams on this date of service. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the x-rays have not been met. CPT Codes 73030 and 72050 were 
paid over the allowed amount per the 2022 Physician Fee Schedule. Per the Fee Schedule, CPT 73030 should 
have only had an allowed amount of $9.02; however, the Plan allowed $19.08 ($10.06 over). CPT 72050 
should have only had an allowed amount of $13.02; however, the Plan allowed $13.76 ($0.74 over). Per 
Medicare Claims Processing Manual Chapter 13, Section 20.1, "A/B MACs (B) must pay for the PC of 
radiology services furnished by a physician to an individual patient in all settings under the fee schedule for 
physician services regardless of the specialty of the physician who performs the service." Due to the claim 
processing over the allowed amount noted in the Physician Fee Schedule, this claim has processed correctly. Therefore, we decided that the Plan does not have to pay for the shoulder x-ray (73030-26) and the neck x-ray 
(72050-26) provided on September 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening (76706) 
provided on January 13, 2022. 
 You asked the Plan to pay for the AAA screening. You say that this test should be covered. The Plan denied 
your request. The Plan says this test is only covered once per lifetime. You previously had this exam on 
December 29, 2020. The test at issue exceeds the limitation of one per lifetime. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The rules say that a one-time abdominal aortic 
aneurysm screening is covered if you have certain risk factors and get a referral from your physician. 
 
The test at issue in this appeal, the AAA screening, was provided in excess of coverage. The records show that 
you previously had this one-time exam on December 29, 2020. This screening is not covered more than once. 
Therefore, we decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening 
(76706) provided on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the CardioMEMS device has 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an initial hospital inpatient care per day, typically 50 minutes 
(99222) provided on October 24, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this claim should be paid as billed. The Plan 
denied your request. The Plan says current procedural terminology (CPT) code 99222 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is an initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 minutes must be met or exceeded. 
 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 inpatient care. Our reviewer says that the documentation 
does not support procedure code 99222. Our reviewer found that the history is comprehensive.  The physical 
examination is not comprehensive.  The medical decision making is of moderate complexity.  As such, the 
billing of procedure code 99222 is not supported.  
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for an initial hospital inpatient care per day, typically 50 minutes (99222) provided on October 
24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that external causes of morbidity codes (V00-Y99) 
should never be sequenced as the first-listed or principal diagnosis.  
 
We looked at the file and Medicare rules. In this case, diagnosis code W06.xxxA was billed as the principal 
diagnosis. Per ICD-10-CM guidelines, this code should not be billed as the principal diagnosis. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the ambulance services provided on December 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) assessment using the 
ImpediMed L-Dex testing device. 
 
You asked the Plan to pre-approve BIS assessment device. You say that the enrollee is at high risk for 
developing lymphedema. You also say that the use of ImediMed's L-Dex device is medically necessary. The 
Plan denied your request. The Plan says the requested device 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 BIS assessment device. Our reviewer 
says that the requested BIS assessment device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found bioimpedance devices for detection of lymphedema are considered 
investigational. Therefore, the reviewer found that the requested BIS assessment device 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 BIS assessment device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bioimpedance spectroscopy (BIS) assessment using the ImpediMed L-Dex testing 
device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
May 11, 2022. 
 
You asked the Plan to pay for the panel. 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 pay for the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a 
urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex PCR urinary tract infection panel tests. Urine PCR amplification techniques raise considerable 
concerns regarding contamination from one specimen to another, creating the potential for false-positive 
results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms 
representing latent infection or colonization cannot be distinguished from active, clinically significant 
infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus 
further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative 
predictive values of PCR have not been reported in large groups of patients for many of the microorganisms. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine polymerase chain reaction (PCR) panel provided on May 11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (darbepoetin alfa) (J0881). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs Retacrit or Procrit. The Plan states there is no indication the preferred drug(s) would likely be: less effective, 
and/or cause adverse effects for the enrollee. 
 
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 the medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Retacrit or Procrit. The documentation 
does not support that Retacrit or Procrit would likely be less effective, and/or would likely have adverse effects 
for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp (darbepoetin alfa) (J0881).
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 services are necessary for you to receive the care 
needed. The Plan denied your request. The Plan says your needs can be met with intermittent physical and 
occupational therapy. 
 
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 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 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 pre-approve the VIA Disc NP. 
 
You asked the Plan to pre-approve the VIA Disc NP. You say that the VIA Disc NP is medically necessary. 
The Plan denied your request. The Plan says the VIA Disc NP 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 VIA Disc NP. Our reviewer says 
that the requested VIA Disc NP is not considered medically reasonable and necessary. Our physician reviewer 
found that large, well-designed studies in the peer review scientific literature comparing stand-alone use of 
VIA Disc to established treatments are needed. Published studies do not demonstrate any long-term health 
outcome advantage with the use of VIA Disc NP as an alternative to standard treatments. The review has 
determined that the services at issue in this case are 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 VIA Disc NP have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the VIA Disc NP.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery; intermediate (77523). 
 
You asked the Plan to pre-approve proton treatment delivery. You say that the requested therapy is medically 
necessary and superior care for the enrollee's prostate cancer. The Plan denied your request. The Plan says the 
request is not medically necessary. The requested treatment does not meet the requirements for approval. 
 
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 proton treatment delivery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the most recent NCCN guidelines for prostate cancer summarize the published 
literature, acknowledge the ASTRO guidelines, discuss that dosimetric comparisons studies between proton 
therapy and IMRT, and state that These studies suffer from the biases and talents of the investigators who plan 
and create computer models of dose deposition for one therapy or the other. Although dosimetric studies in-
silico can suggest that the right treatment planning can make an IMRT plan beat a proton therapy plan and vice 
versa, they do not accurately predict clinically meaningful endpoints. There is no clear evidence that proton 
beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. 
Clinical trials are necessary to establish a possible advantage of this expensive therapy. To date, there is no 
compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to enrollees. While NCCN guideline consider proton therapy a reasonable 
alternative they do not describe it as being necessary in lieu of non-proton-based treatment and are quite 
explicit in that there is no evidence of its superiority. The decision is unfavorable as the reviewer does not 
believe the LCD criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery; intermediate (77523).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee cannot use corticosteroids. You 
also say that the enrollee needs this medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Skyrizi.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.