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

 
We decided that the Plan does not have to pre-approve the Maze procedure with an inpatient hospital 
admission. 
 
You asked the Plan to pre-approve the Maze procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says off-pump Maze procedures, including Hybrid or 
convergent ablation procedures, are considered investigational as a treatment of atrial fibrillation or flutter. 
 
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 Maze procedure. Our reviewer says 
that the requested Maze procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found supportive, randomized, longer-term clinical studies are awaited, including direct 
comparisons of hybrid ablation procedures with alternative treatment options.  Therefore, the reviewer found that the request for the performance of a convergent hybrid ablation procedure, or in this case a stand-alone 
surgical off-pump MAZE procedure, would not be considered appropriate and reasonable in the enrollee's 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Maze procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Maze procedure with an inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's current condition is too 
complex for lower levels of care. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for LTACH as they can safely receive the necessary care in another setting. 
 
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 but requires short-term additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer to a 
lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the long-term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 00566-QK-P4 (232 units) billed for date of service October 
17, 2022. 
 
You asked the Plan to pay for 00566-QK-P4 (232 units). You say that these services should be paid. The Plan 
denied your request. The Plan says the billing of 00566-QK-P4 (232 units) is not supported by the medical 
record. The records do not support the number of units billed. The Plan also says that that code 76937-26 has 
been approved and is not at issue. 
 
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 00566-QK-P4 is Anesthesia for direct coronary artery 
bypass grafting; without pump oxygenator. 
 
 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 00566-QK-P4 (232 units). Our reviewer says that 00566-
QK-P4 (232 units) is not supported by the medical record. Our reviewer found the procedure codes performed 
did not require additional anesthesia to be billed with it. Also, the base value for the 00566 is 25, therefore the 
232 units is also not supported or verified with the medical records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 00566-QK-P4 (232 units) have not been met. Therefore, we decided that the 
Plan does not have to pay for 00566-QK-P4 (232 units) billed for date of service October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3D printed finger/partial finger prosthesis. 
 
You asked the Plan to pre-approve the item. You say that this is needed to extend finger length, protect the 
residual limb, and enable her to type. The Plan denied your request. The Plan says in this case, there is 
insufficient evidence that a partial finger prosthesis serves a medical purpose. It is primarily used for cosmetic 
reasons. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has sensitivity of the distal left finger and there is no evidence that the enrollee will be 
able to use this device effectively for typing given their discomfort. Per a 2/2/23 medical progress note, the enrollee is able to care for herself, and is currently retired. There are no objective finger measurements notes 
supporting a significant length discrepancy between the hands that would inhibit typing.  
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a 3D printed finger/partial finger prosthesis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulater 
electrode array, epidural - 2 units (63650). 
 
You asked the Plan to pre-approve the services. You say that this procedure would benefit the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried conservative treatments. the enrollee has not 
attempted other treatment modalities, or that they are unsuitable or contraindicate to this case. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no records of a referral to physical therapy or home exercise or explicit reasons why 
the enrollee cannot perform these therapies before having a spinal cord stimulator trial. The records do not show that the enrollee has not attempted other treatment modalities, or that they are unsuitable or 
contraindicated in the enrollee's case. The review has determined that the requested service 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous implantation of neurostimulater electrode array, epidural - 2 units 
(63650).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gauze (A6220) provided on April 1, 2022. 
 
You asked the Plan to pay for the out-of-network services. You say that these supplies are a separately billable 
expense that does not require separate authorization and have not been included in any other billing to treat the 
wounds described in the attached medical record documentation. The Plan denied your request. The Plan says 
this provider is out-of-network, the services were not referred by a network provider, and the services were not 
urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the gauze (A6220) provided on April 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that there is an in 
network SNF. 
 
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 
SNF care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the professional services for the supervision of preparation 
and provision of antigens for allergen immunotherapy (95165) provided on March 31, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the billed units are 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 95165 is professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses). 
 
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 found the record does not support 
24 units of 95165. The record states that 2 vials of 5 milliliter (ml) each were prepared, for a total of 10 ml. 
According to National Correct Coding Initiative (NCCI) policy, a unit equals 1 cubic centimeter (cc)/ml, so 10 
units are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the professional services for the supervision of preparation and provision of antigens for 
allergen immunotherapy (95165) provided on March 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion subcutaneous cardiac rhythm monitor (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder (ILR). You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the documentation does not show that 
the enrollee has had any syncopal episodes. The Plan also says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 implantable loop recorder (ILR). 
Our reviewer says that the requested implantable loop recorder (ILR) is not medically necessary. Our physician 
reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR device. Therefore, the reviewer found that the requested ILR 
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 implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion subcutaneous cardiac rhythm monitor (33285).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 21, 2022, to 
December 15, 2022. 
 You asked the Plan to pay for the home health services. 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 October 21, 2022. The NOA was not received by the Plan until December 
31, 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 the home health services 
provided from October 21, 2022, to December 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for allergy testing (95165) provided on February 9, 2023. 
 
You asked the Plan to pay for the allergy testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the records do not support the billed service. 
 
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 95165 is supervision of preparation and provision of antigens for allergen immunotherapy; single or 
multiple antigens. 
 
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 allergy testing. Our reviewer says that the billed service 
is supported in the records. Our reviewer found the documentation does support the use of procedure 95165. 
The breakdown of the antigens was reported as well as the mixture the provider performed. 
 
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 allergy testing have been met. Therefore, we decided that the Plan has to 
pay for allergy testing (95165) provided on February 9, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T7, T8, and T9 kyphoplasties. 
 
You asked the Plan to pre-approve the kyphoplasties. You say that the enrollee's quality of life is declining. 
You also say this is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
documentation indicates that the enrollee's pain is improving. The Plan says there is no documentation of 
optimal non-surgical management or a vertebral height reduction of greater than 25% at T7, T8 and T9. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP) is covered in patients with osteoporotic VCF when the enrollee is symptomatic and non-
hospitalized with moderate to severe pain despite optimal non-surgical management . 
 
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 kyphoplasties. Our reviewer says 
that the requested kyphoplasties for T7, T8 and T9 are not medically necessary. Our physician reviewer found 
the provided documentation does not support that the enrollee has trialed non-surgical management, including a 
back brace for the fracture. Therefore, the reviewer found that the requested kyphoplasties are not medically 
reasonable or necessary at this time. 
 
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 kyphoplasties have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T7, T8, and T9 kyphoplasties.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 8, 2023. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant of patent foramen ovale (PFO) closure device 
(93580). 
 
You asked the Plan to pre-approve the PFO closure device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of percutaneous 
closure of patent foramen ovule in the setting of advanced age have not been demonstrated in 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 PFO closure device. Our reviewer 
says that the requested PFO closure device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates a history of stroke and presence of PFO noted on echocardiography. The reviewer found that guidelines point to a recommended age limit of 60 years 
for this procedure. The reviewer found that there is insufficient documentation to support the medical necessity 
for the requested PFO closure device. Therefore, the reviewer found that this 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 PFO closure device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implant of patent foramen ovale (PFO) closure device (93580).
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 cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee is receiving the appropriate care and does not require transfer to an LTACH. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 21, 2022, to 
October 20, 2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA was submitted.  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 September 21, 2022. The NOA was not received by the Plan until 
November 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 September 21, 2022, to October 20, 2022.