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

 
We decided that the Plan does not have to pre-approve left heart catheterization and ventriculography. 
 
You asked the Plan to pre-approve left heart catheterization and ventriculography. You say that the requested 
left heart catheterization and ventriculography is medically necessary. The Plan denied your request. The Plan 
says the requested left heart catheterization and ventriculography 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 left heart catheterization and 
ventriculography. Our reviewer says that the requested left heart catheterization and ventriculography is not 
medically necessary. Our physician reviewer found at issue is the medical necessity for performance of cardiac 
catheterization for evaluation of shortness of breath. There is no chest pain. The enrollee has a history of 
coronary bypass graft surgery. A stress test has not been performed. Guidelines do not support a need for 
cardiac catheterization in this setting. As a result, at this time cardiac catheterization 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 left heart catheterization and ventriculography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve left heart catheterization and ventriculography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (J0882) provided on November 7, 2022 to 
November 30, 2022. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code J0882 is not supported in the medical record. Specifically, the claim was not billed with 
a required modifier (JA, JB, JE). Based on this information, we decided that Medicare rules for coverage of the 
injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (J0882) 
provided on November 7, 2022 to November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81432, 81433). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial and have 
submitted medical records to support the reconsideration of the denied genetic testing. The Plan denied your 
request. The Plan says you do not meet criteria for approval of the requested genetic testing. 
 
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. The records show that according to the clinical information provided, 
we are unable to determine if you are seeking medical treatment for your cancer or how these test results will 
impact your current treatment plan for cancer. You do not meet criteria for approval of genetic testing per LCD 
35000. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81432, 81433).
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 to the hospital for surgical management of spinal stenosis and 
compression fractures. You are now medically stable with 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. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic cardiac risk assessment screening provided August 
26, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this enrollee's provider ordered this test and assess 
the enrollee' situation and determined this service was medically necessary The Plan denied your request. The 
Plan says this service does not meet Medicare coverage criteria. 
 
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 genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the test is described as a genetic based cardiovascular risk factor screening test in which 
multiple genes are assessed using genomic deoxyribonucleic acid (DNA) extracted from patient sampling. It 
assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated with 
increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in this enrollee's 
clinical management. In summary, the requested testing is not considered reasonable or 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic cardiac risk assessment screening provided August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is to undergo a procedure, which is not on the inpatient only list and is not expected to require two midnights of inpatient level care. The enrollee should present, undergo 
the procedure, and be monitored as an outpatient. Should complications arise, warranting a prolonged stay, the 
enrollee can be converted to inpatient status, at that time, under the two-midnight rule. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 6, 2022, to August 
4, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
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 July 6, 2022. The NOA was not received by the Plan until September 9, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from July 6, 2022, to August 4, 2022.
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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet all of the requirements.  
 
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 your nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional counseling, dietitian visit. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says healthy food-based treatment provided by a registered 
dietitian nutritionist is not covered by your benefit Plan. Medical nutrition therapy is a covered benefit for 
people with diabetes, renal (kidney) disease (but not on dialysis), or after a kidney transplant when ordered by 
your doctor. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve nutritional counseling, dietitian visit.
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 enrollee needs SNF for physical and 
occupational therapy. The Plan denied your request. The Plan says the enrollee's clinical condition does not 
require daily skilled nursing care as an inpatient as per guidelines. 
 
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 enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 24, 2022. 
 
You asked the Plan to pay for the medical services. You say that the member's hospice was terminated before 
the date of service at issue. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 23, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on December 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BRCA1 and BRCA2 genetic testing (81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that the provider wants the enrollee tested 
because the enrollee has a history of cancer. The Plan denied your request. The Plan says the Medicare rules 
have not been 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 the genetic testing. Our physician 
reviewer found the enrollee has a family history of breast cancer. The enrollee has no personal history of breast 
or ovarian cancer. The review indicates that the medical records provided do not meet the requirements listed 
in the LCD for Medicare 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the BRCA1 and BRCA2 genetic testing (81162).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 28, 2022, to 
September 26, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly. 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 January 30, 2022. The NOA was not received by the Plan until December 
23, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 28, 2022, to September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service March 10, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you have billed the items at issue correctly. 
The Plan denied your request. The Plan says the billed code is bundled or excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code A4239 has a Status Indicator of P on the Physician Fee Schedule. This means that 
no separate payment may be made for procedure code A4239. Based on this information, we decided that 
Medicare rules for coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4239 billed for date of service March 10, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for chiropractic services provided from 
December 9, 2022, to December 14, 2022. 
 
You asked the Plan to waive the copayment for the chiropractic services. You say that you have a zero 
copayment for chiropractic services provided by a contracted provider. The Plan denied your request. The Plan 
says that the Plan did not make a decision within the timeframe. 
 
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 has not provided a Plan rule to substantiate their denial. 
Therefore, we decided that the Plan has to waive the copayment for chiropractic services provided from 
December 9, 2022, to December 14, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and stealth gel 
footplate pads (A9270). 
 
You asked the Plan to pre-approve a power seat elevation system and stealth gel footplate pads. You say that 
you would like the medical necessity of this equipment for this enrollee to be reviewed. The Plan denied your 
request. The Plan says these accessories do not meet medical necessity per Medicare criteria. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that a power seat elevation feature (E2300) is non-covered because it 
is not primarily medical in nature.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and stealth gel 
footplate pads (A9270).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the NuTech NuCel allograft (20930). 
 
You asked the Plan to pre-approve the allograft. You say that the service is medically necessary. The Plan 
denied your request. The Plan says medical studies have not proven that the use of this product during spinal 
surgery is better than standard allograft products (material used during surgery to help new bone grow).  
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested NuTech NuCel Allograft for the approved inpatient spinal 
surgery, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the NuTech NuCel allograft (20930).