Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the IRF services you are requesting do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, rehabilitation, and medical, needs does not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. 
The enrollee is medically stable, and no acute rehabilitation nursing needs were identified or documented. 
While the enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation needs can 
be provided in a lower intensity and alternate 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87900) provided on December 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 87900 is "Infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics". 
 
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 services. Our reviewer says that the use of code 87900 is 
not supported by the records provided. Our reviewer found that the laboratory report does not include 
documentation of quantitative prediction of the drug susceptibility phenotype for each antiretroviral drug with a numeric measure and assessment, This procedure was not found in medical record. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (87900) provided on December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (1390) and a portable gaseous 
oxygen system (K0738). 
 
You asked the Plan to pre-approve oxygen equipment. You say that your son needs the requested oxygen. The 
Plan denied your request. The Plan says this request does not meet Medicare guidelines for oxygen. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of oxygen equipment have not been met. Specifically, the Plan has not received documentation that 
shows your arterial oxygen level to be at or below 55 mm Hg or an arterial oxygen saturation at 
or below 88 percent taken at rest (awake) or for 5 minutes while asleep. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator (1390) and a portable gaseous oxygen system (K0738).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total disc arthroplasty. 
 
You asked the Plan to pre-approve total disc arthroplasty. 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. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 total disc arthroplasty have been met. Specifically, medical records were not received. Medical necessity cannot be established without this 
documentation. Therefore, we decided that the Plan does not have to pre-approve total disc arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from October 6, 2022, to October 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99233-FS (1 unit) 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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
available for review doesnt support the CPT code 99233 on 10/06/2022 and 10/07/2022. The documentation 
available for review does not support the member developed a significant complication or that medical decision 
making of high complexity was needed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered from October 6, 2022, to October 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXBladder Monitor test provided on October 5, 2022.  
 
You asked the Plan to pay for the testing. You say that this testing was medically necessary.  The Plan denied 
your request. The Plan says this test is experimental and investigational. At this time, the peer-reviewed 
medical literature does not support these tests as having sufficient sensitivity or specificity necessary to define 
their clinical role. 
 
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 testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the CXBladder Monitor test provided on October 5, 2022, was not medically reasonable and 
necessary in this case. To date, there are multiple urine markers that have improved sensitivity over cytology 
but there is lack of validation of clinical utility. There is insufficient reliable evidence in the peer reviewed 
medical literature to establish the efficacy or effects on health care outcomes. Further prospective validations 
are needed to confirm these findings. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the CXBladder Monitor test provided on October 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on November 25, 
2022. 
 
You asked the Plan to pay for the ambulance transportation . You say that this trip should be separately 
payable.  The Plan denied your request. The Plan says the enrollee remained inpatient at the transferring facility 
during this trip. As such, payment is included in Part A payment to the hospital.  
 
The Plan must follow Medicare rules. Medicare rules say that transfer of a patient to a different facility while 
the patient remains inpatient is considered "patient transportation" and is covered as an inpatient hospital 
service.  
 We looked at the file and Medicare rules. The enrollee was an inpatient at the time of this transport. As such, 
separate Part B payment cannot be made. Based on this information, we decided that Medicare rules for 
coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have 
to pay for the ambulance transportation provided on November 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.9 
rendered from June 15, 2021, to June 21, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the enrollee was not hypotensive, hypoxic, or confused. The enrollee had normal platelets 
and normal renal and liver function.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code A41.9 rendered from June 15, 2021, to June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on August 4, 2022. 
 
You asked the Plan to pay for initial hospital care (99223). You say that this evaluation and management 
service supports the level of service assigned and was medically necessary. The Plan denied your request. The 
Plan says the medical records submitted do not support a comprehensive history. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 initial hospital care (99223). Our reviewer says that the 
documentation does not support procedure code 99223 based on the key components in the code description. 
Our reviewer found this initial hospital care evaluation and management code requires a comprehensive 
history, a comprehensive examination and medical decision making of high complexity. In this case, the 
medical records submitted do not support a comprehensive history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) provided on August 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services (G0299). 
 You asked the Plan to pre-approve home health services. You say that the 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 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 
documentation does not support that you require additional skilled rehabilitation services to provide treatment 
that is medically necessary. You do not require additional skilled rehabilitation services to effectively provide 
treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain 
your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. The requested home health services are 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 the home health services (G0299).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi (Q5107). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has a diagnosis of malignant 
neoplasm of right lobe involving bronchus or lung. You say that the enrollee has multiple treatments including 
chemotherapy and sotorasib for their tumor.  The Plan denied your request. The Plan says Mvasi is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our physician reviewer 
found the requested use of Mvasi is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS)-approved medical journal  
 
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 Mvasi (Q5107).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti (Q5117) , Carboplatin (J9045), Paclitaxel 
(J9267), and Bevacizumab-awwb (Q5107) 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has metastatic endometrial cancer.  
The Plan denied your request. The Plan says the medication regimen is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our physician reviewer 
found the requested use of Kanjinti, Carboplatin, Paclitaxel, Bevacizumab-awwb is not FDA-approved for the 
enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. 
 
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 Kanjinti (Q5117) , Carboplatin (J9045), Paclitaxel (J9267), and Bevacizumab-awwb 
(Q5107)
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from May 29, 2023, forward. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 the clinical documentation shows that you are not at baseline clinical or functional 
status but there is no documentation to show that you require daily skilled services. Clinical documentation 
only shows that you are unable (or unsafe) to be discharged to previous living situation. From a practical 
standpoint, the documentation does not show that you require daily skilled services on an inpatient basis in a 
skilled nursing facility; thus, the continuation of SNF care 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care from May 29, 2023, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CX Bladder Detect test (81479) provided on February 15, 
2022. 
 
You asked the Plan to pay for the testing. You say that this testing was medically necessary.  The Plan denied 
your request. The Plan says  the CX Bladder panel remains unproven at this time.  
 
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 testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found CxBladder is not considered a screening test for urothelial cancer. To date, there are multiple 
urine markers that have improved sensitivity over cytology but there is lack of validation of clinical utility. 
There is insufficient reliable evidence in the peer reviewed medical literature to establish the efficacy or effects 
on health care outcomes. Further prospective validations are needed to confirm these findings. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the CX Bladder Detect test (81479) provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V Leiden. 
 
You asked the Plan to pre-approve Factor V Leiden. 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 genetic testing for these genes for all risk factors, 
signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for 
pregnant patients. 
 
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 Factor V Leiden. Our reviewer says that 
the services are not medically necessary Our physician reviewer found the reviewed documentation indicates 
that the enrollee has a recent diagnosis of pulmonary embolism. Medicare states this is a non-covered test, 
except for pregnant patients who have a history of personal venous thromboembolism (VTE) associated with a 
non-recurrent (transient) risk factor who are not otherwise receiving anticoagulant prophylaxis. The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Factor V Leiden have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Factor V Leiden.