Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (code 99223) provided on December 
30, 2022.  
 
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says the medical 
records 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 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 physician services. Our reviewer says 
that the criteria for coverage has not been met. Our reviewer found the records supported that there was a 
comprehensive exam and medical decision making of high complexity, but the records did not support that 
there was a comprehensive history. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for the physician services (code 99223) provided on December 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration as 
the enrollee currently meets IRF criteria. The Plan denied your request. The Plan says criteria for admission to 
the acute IRF setting have not been met.  
 
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, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior lumbar arthrodesis procedure using the 
Minuteman G3-R MIS fusion plate (22612, 22840). 
 
You asked the Plan to pre-approve the Minuteman device. You say that authorization was given for the 
removal of Vertiflex device. You also say that the insertion of the posterior-lateral arthrodesis at L3 to L4 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 the Minuteman device. Our reviewer 
says that the requested Minuteman procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Minuteman fusion device is experimental as additional research is needed. Therefore, the reviewer found that the requested 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 the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a posterior lumbar arthrodesis procedure using the Minuteman G3-R MIS fusion 
plate (22612, 22840).
Appeal type: DME/ Orthotics
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 CardioMEMS device. You say that the enrollee needs this device. 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 the CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is 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. Therefore, the reviewer 
found that the requested 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (33289).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 70496 and 70498. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 0042T-26.  
 
You asked the Plan to pay for radiological services provided on January 13, 2023, billed with codes 70496-26, 
70498-26, and 0042T-26. You say that the claim is billed correctly and should be paid. The Plan says that code 
0042T was billed with an invalid modifier. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 70496 and 70498.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 70496 and 70498.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
0042T-26. 
 
The Plan follows Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 0 identifies codes that describe physician services. Modifiers 26 & TC cannot be 
used with these codes. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 0042T-26 have not been met. Procedure code 0042T 
has a status indicator of 0 and was inappropriately billed with a -26 modifier. Therefore, we decided that the 
Plan does not have to pay for the services described by procedure code(s) 0042T-26. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for rhabdomyolysis after a fall. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical 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 you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lateral transverse arthrodesis procedure (20930, 
22612).  
 
You asked the Plan to pre-approve a lateral transverse arthrodesis procedure. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says that this procedure 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 a lateral transverse arthrodesis 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found a lateral transverse arthrodesis procedure is experimental, 
and more research is needed. 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 lateral transverse arthrodesis procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lateral transverse arthrodesis procedure (20930, 22612).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the physical therapist is recommending acute 
rehabilitation. You say the last facility you went to didn't give adequate care and didn't work you enough to 
regain maximum function. The Plan denied your request. The Plan says you do not meet the Medicare criteria 
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 your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0315U) provided on November 11, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will only cover and reimburse tests that 
demonstrate analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable 
and necessary requirement. 
 
We looked at the file and Medicare rules. The test at issue (DecisionDX) is not listed by MolDX as an 
approved test. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0315U) 
provided on November 11, 2022.
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 physician 
monitoring to ensure their condition does not worsen. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0315U) provided on December 12, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will only cover and reimburse tests that 
demonstrate analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable 
and necessary requirement. 
 
We looked at the file and Medicare rules. DecisionDX is not listed as an approved test by MolDX. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (0315U) provided on December 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous angioplasty (PTA) and stent placement 
(37215). 
 You asked the Plan to pre-approve PTA and stent placement. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare covers PTA of the carotid artery concurrent 
with the placement of an FDA-approved carotid stent with embolic protection 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 PTA and stent placement. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records fail to indicate that 
the enrollee is not a suitable candidate for carotid endarterectomy (CEA). Guidelines are clear that such a 
procedure would be authorized only if he were not a candidate for CEA. As such, PTA and stent placement 
would not be considered medically necessary in this patients 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 PTA and stent placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous angioplasty (PTA) and stent placement (37215).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of subcutaneous compounded hormone 
replacement pellets (11980). 
 
You asked the Plan to pre-approve the use of hormone replacement pellets. You say that hormone replacement 
therapy is 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 the use of hormone replacement pellets. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that, based on the medical records provided and the Medicare-approved 
major drug compendia, there is no support for the use of subcutaneous compounded testosterone 50 mg/estradiol 25 mg pellets for treatment of menopausal symptoms. 
 
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 use of hormone replacement pellets have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the use of subcutaneous compounded hormone replacement 
pellets (11980).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits 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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is diagnosed with chronic 
obstructive pulmonary disease (COPD) exacerbations requiring hospitalization twice in 30 days. The Life2000 
will help her to be more active in and outside her home and will significantly improve her quality of life. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator set in AC mode with very 
low tidal volumes that could be delivered by BiPAP is not covered. 
 
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 record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the 
enrollee was successfully treated with BiPAP. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability and failure of such a device has not been 
documented. The plan has indicated coverage for such a device is available upon request. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).