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 enrollee has a skin breakdown and enrollee must get 
treated for cancer. They need to go to inpatient rehab because the enrollee is stuck in the bed and needs help to 
walk. The Plan denied your request. The Plan says this is not medically necessary, the services they need can 
be provided safely in other settings. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 5, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 5, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 
0032U and 0033U.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit and a radiologic examination, knee provided on 
October 14, 2021. 
 
You asked the Plan to pay for the office visit and a radiologic examination, knee. You say that this visit was 
about a knee problem. You say that the medical records show different dates, one being the carpal tunnel and 
the current claim is about bilateral knee pain. The Plan denied your request. The Plan says that this service is 
mutually exclusive to the primary procedure and isnt allowed separately. 
 
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 the rule used to deny the claim or a 
coding review to support the denial. Therefore, we decided that the Plan has to pay for an office visit and a 
radiologic examination, knee provided on October 14, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contour next test strips. 
 
You asked the Plan to pre-approve contour next test strips. You say that these test strips are needed to test your 
blood sugar levels. The Plan denied your request. The Plan says that you do not meet prior authorization 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
 
 
 
 We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of test strips. Without this, medical necessity cannot be 
established. Based on this information, we decided that Medicare rules for coverage of contour next test strips 
have not been met. Therefore, we decided that the Plan does not have to pre-approve contour next test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee continues to be high risk for 
infection and poor wound healing. The enrollee requires daily physician oversight with specialty consults, 
complex wound care by a dedicated wound care team, and specialized nursing care with medication 
administration including anti-infectives and pain control. The Plan denied your request. The Plan says this is 
not medically necessary, and continued acute hospital stay was offered, until the member could discharge to a 
lower level of care. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Allofuse DBA Signafuse allograft. 
 
You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of the Allofuse DBA Signafuse 
allograft is experimental in nature, as more research is needed to show its safety and efficacy. The services are 
therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Allofuse DBA Signafuse allograft.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Erbitux (J9055). 
 
You asked the Plan to pre-approve Erbitux. You say that this is the enrollee's last treatment option. The Plan 
denied your request. The Plan says that the requested drug/regimen is not being prescribed for a supported 
medically accepted indication. 
 
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 Erbitux. Our reviewer says that Erbitux 
is reasonable and necessary for the enrollee. Our physician reviewer found the use of Erbitux is supported by 
the National Comprehensive Cancer Network (NCCN) guidelines. Our reviewer also found that the enrollee 
has KRAS wild-type, and has exhausted standard therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Erbitux have been met. Therefore, we decided that the Plan has to pre-approve 
Erbitux (J9055).  
 
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: Favorable

 
We decided that the Plan has to pay for the inpatient services provided from May 9, 2022, to May 12, 2022. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says that this was 
a readmission for the same diagnosis. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 services. Our reviewer says 
that the requested inpatient services were medically reasonable and necessary in this case. Our physician 
reviewer found that the readmission was medically necessary. The readmission was not the result from a 
premature discharge from the same hospital. The enrollee was stable and appropriate for discharge on April 21, 
2022, at the time of the last hospitalization.  
 
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 inpatient services have been met. Therefore, we decided that the Plan has to 
pay for the inpatient services provided from May 9, 2022, to May 12, 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 pay for the continuous glucose monitor supplies billed for February 
28, 2022, to March 30, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation did not include proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor supplies billed for February 28, 2022, to March 30, 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. You say that you are requesting inpatient rehabilitation for the 
enrollee. The Plan denied your request. The Plan says the enrollees needs can be met at a lower level of care 
such as skilled nursing facility (SNF), home health or outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
  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 genetic testing (81529) provided on February 18, 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 coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 genetic testing (81529) provided on 
February 18, 2022. have been met. Records provided were limited to the pathology report. No clinical records were submitted to show that this service meets coverage criteria. Therefore, we decided that the Plan does not 
have to pay for genetic testing (81529) provided on February 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport (A0428, A0425) provided on September 28, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the 
ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance 
transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, non-
emergency transport. Our reviewer says that ambulance service, basic life support, non-emergency transport 
was not medically necessary. Our physician reviewer found that the documentation does not support that other 
means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this enrollee on September 28, 2021. The enrollee was able to stand and walk to the 
stretcher for transport. Other means of transport would have been reasonable. The documentation does not 
support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on September 28, 2021. The enrollee was discharged 
from the emergency department after an evaluation was being transported to her place of residence. The 
enrollee was stable and required no basic life support or advanced life support evaluation or 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 ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on September 28, 2021.
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 the enrollee would benefit from the intensity of an 
IRF. The Plan denied your request. The Plan says needs can be met at an alternate level of care. The Plan 
would approve skilled nursing facility (SNF) if requested. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block (MBB) injections (64493, 64494), 
bilateral. 
 
You asked the Plan to pre-approve the MBBs. You say that the requested MBB injections are medically 
necessary for the enrollee due to chronic pain syndrome. The Plan denied your request. The Plan says all of the 
criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary for patients when all the criteria are 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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the provided documentation does 
not indicate that the enrollee received an epidural steroid injection (ESI) in November 2021. The reviewer 
found there was no documentation provided indicating the percentage or pain relief or the duration the enrollee 
received from the ESI. Therefore, the reviewer found that the requested MBBs are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MBBs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve medial branch block (MBB) injections (64493, 64494), bilateral.