Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the records provided support the need for an 
implantable loop recorder. The Plan denied your request. The Plan says the requested service is not medically 
necessary because the enrollee has not had a stroke and has not had an external monitoring. 
 
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 an ILR. Our reviewer says that an ILR 
is not considered medically reasonable and necessary in this case. Our physician reviewer found while the 
enrollee has a history of palpitations and atrial fibrillation, there is no documentation provided to suggest a 
history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. There is 
insufficient documentation to support the medical necessity for insertion of an ILR 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral 
branches. 
 
You asked the Plan to pre-approve RFA of the lateral sacral branches. You say that the clinical documentation 
provided supports the need for the requested injection services. The Plan denied your request. The Plan says the 
requested services are considered experimental, investigational, and unproven. 
 
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 RFA of the lateral sacral branches. Our 
reviewer says that RFA of the lateral sacral branches is not considered medically reasonable and necessary in 
this case. Our physician reviewer found this procedure is considered experimental due to the wide variation 
efficacy reported in the literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the lateral sacral branches have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (73522) provided on May 4, 2022. 
 
You asked the Plan to pay for an x-ray. You say that this is supported in the documentation. The Plan denied 
your request. The Plan says the record does not support that 3 or 4 views were taken. 
 
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 73522 is radiologic examination, hips, bilateral, with 
pelvis when performed; 3-4 views. 
 
We find that CPT code 73522 is not supported in the medical record. Specifically, the record does not 
document than an x-ray with 3 to 4 views was taken. Based on this information, we decided that Medicare rules 
for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-
ray (73522) provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81335, 81355, 81406, 81407, 0031U, 0032U, 
& 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 
March 8, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81335, 81355, 
81406, 81407, 0031U, 0032U, & 0033U.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor kit. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor kit. You say that you have type 2 diabetes. 
You have been pricking your fingers 4-5 times a day and this seems to show some kind of relief. The Plan 
denied your request. The Plan says you do not meet coverage criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day continuous glucose monitor (CGM) sensor kit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee lives at an assisted living facility, and 
they will not take them back due to not having 24-hour care. The Plan denied your request. The Plan says as 
from the standpoint of skilled nursing needs, we did not see that they meet Medicare criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The 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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like admission to an IRF. You say that 
these services are needed for your care. The Plan denied your request. The Plan says that you do not meet the 
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 skilled therapy, there is no documented need 
for intensive rehabilitation services. Medically necessary care can be provided in 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 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Amvuttra. 
 
You asked the Plan to pre-approve Amvuttra. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet coverage criteria for this medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Amvuttra. Our reviewer says that the 
requested use of Amvuttra is medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of neuropathic heredofamilial amyloidosis. The Food and Drug Administration has 
stated that the requested drug is indicated for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Amvuttra have been met. Therefore, we decided that the Plan has to pre-
approve Amvuttra.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 1, 2022, to 
February 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare by mail, electronic data interchange (EDI), or direct data entry (DDE).  
 
We looked at the file and Medicare rules. The file shows that the NOA submitted was for admission date of 
January 5, 2022, not the billed dates of service. 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 pay for the 
home health services rendered on February 1, 2022, to February 3, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine and left 
shoulder. 
 
You asked the Plan to pre-approve MRI services. You say that this service is necessary to evaluate the 
enrollee's problem and resolve symptoms. The Plan denied your request. The Plan says that the requested MRI 
is not medically necessary and reasonable. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI services. Our reviewer says that 
the requested services are reasonable and necessary. Our physician reviewer found that the enrollee has neck 
pain and a decreased range of motion. The enrollee has made some improvement with more than four weeks of 
physical therapy but is still symptomatic. The enrollee uses a TENS unit at home. Previous x-rays showed 
diffuse degenerative changes and facet arthropathy. The enrollee has tried conservative therapy including 
Gadopentin but is still symptomatic. The MRI of the cervical spine should be approved. In addition, the 
enrollee has had a long history of left shoulder issues relating to trauma from 30 years ago. X-rays showed 
degenerative osteoarthritis. The enrollee has had an intra articular injection of steroids in addition to the TENS 
unit. Physical therapy has been done. Based upon the enrollees history, the MRI of the left shoulder is now 
appropriate and should also be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the cervical spine and left shoulder.  
 
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 the genetic testing provided on November 11, 2021, billed 
with codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81335, 81355, 81401, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
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 
November 11, 2021, billed with codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 
81240, 81241, 81291, 81306, 81328, 81335, 81355, 81401, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ear, nose and throat (ENT) services with an in-network 
tertiary level of care provider. 
 
You asked the Plan to pre-approve ENT services at a tertiary level of care. You say that your symptoms require 
treatment from the requested tertiary level of care provider. The Plan denied your request. The Plan says the 
requested provider is a higher-level of care provider than what is required. The Plan says that you can see an 
ENT specialist at a non-tertiary level of care. 
 
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 ENT services at a tertiary level of care. 
Our reviewer says that tertiary care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that you have dizziness. The record provided does not establish 
the medical necessity of a referral to a tertiary care provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ENT services at a tertiary level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve ear, nose and throat (ENT) services with an in-network 
tertiary level of care provider.
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 medically necessary.  
 
 Our physician reviewer found the enrollee was admitted to the hospital for burns and skin grafts. He is now 
medically stable with no complex nursing or rehabilitation needs. He does 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 the enrollee 
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 pay for the genetic testing provided on February 25, 2022 billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81335, 81355, 81406, 
81407, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
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 
February 25, 2022 billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 
81306, 81335, 81355, 81406, 81407, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. 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 March 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from 
October 10, 2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee needs to continue 
rehabilitation treatment to gain more mobility before being discharged. The Plan denied your request. The Plan 
says criteria for a continued SNF stay have not been met. Skilled services can be provided on an intermittent 
outpatient basis, in a long-term care facility, or at the home with home health care services.  
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 continued SNF care. Our reviewer says 
that the requested continued SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found that the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse from October 10, 2022, 
forward. 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care from October 10, 2022, forward.