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

 
We decided that the Plan does not have to pay for lab services provided on May 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service December 
15, 2021. 
 
You asked the Plan to pay for procedure code 71045. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 36556. 
 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 71045 
is a column II code to column I code 36556. 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 71045 billed for date of service December 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for first-hour critical care (99291) billed for date of service 
January 15, 2022. 
 
You asked the Plan to pay for first-hour critical care. You say that the claim is payable as coded and billed. The 
Plan denied your request. The Plan says rules for payment have not been met because the available records do 
not support the service 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. 
 
In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
 
  We find that CPT code 99291 is not supported in the medical record. Specifically, the available medical 
records do not indicate the span of time spent in providing the services at issue. Based on this information, we 
decided that Medicare rules for coverage of first-hour critical care have not been met. Therefore, we decided 
that the Plan does not have to pay for first-hour critical care (99291) billed for date of service January 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this equipment is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is 
considered experimental/investigational. 
 
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 MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve benefits for chronically ill conditions. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do 
not meet the programs criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. The medical records provided do not show that you have met the 
Plans coverage criteria for the requested services. Therefore, we decided that the Plan does not have to pre-
approve benefits for chronically ill conditions.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial strain imaging using speckle tracking. 
 
You asked the Plan to pre-approve the services. You say that the provider stated that you are a good candidate 
for a pacemaker. The Plan denied your request. The Plan says the available peer-reviewed policies indicate that 
this service is investigational at this time. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that speckle-tracking imaging is an echocardiographic technique used in the assessment of myocardial 
function. There is insufficient support in the peer-reviewed literature demonstrating a significant benefit of 
such imaging of the heart in guiding optimal management of patients. As such myocardial imaging using 
speckle tracking is considered experimental and investigational for the evaluation and management of your 
medical 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial strain imaging using speckle tracking.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in pain really needs the rehabilitation. The 
Plan denied your request. The Plan says authorization denied because the IRF care is not medically necessary, 
and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs.  
 
The patient 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve ablation at L5 
and S1 vertebral bodies. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the requested treatment is 
considered experimental and investigational as it is not identified as widely used and generally accepted for the 
proposed use as reported in nationally recognized peer-reviewed medical literature published in the English 
language. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are multiple plausible pathologic sources of significant pain generation. The 
enrollee presented noting the lumbar epidural provided benefit (as provided on July 11, 2022.) The August 22, 
2022, exam requested a repeat lumbar epidural as well as trigger point injections. Also, Significant Modic-type 
changes were not denoted on magnetic resonance imaging (MRI.) Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Intracept intraosseous basivertebral nerve ablation at L5 and S1 vertebral bodies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from December 11, 
2021, to December 14, 2021. 
 
You asked the Plan to pay for hospital services. You say that this claim was billed correctly, and these services 
are supported in the records provided. The Plan denied your request. The Plan says this claim has one or more 
Integrated Outpatient Code Editor (I/OCE) edit errors, and this claim cannot be paid until this information is 
corrected. 
 
The Plan must follow Medicare rules. Medicare rules say that HCPCS code G0378 may only be reported once 
on OPPS bill type 13x claims or non-OPPS bill type 85x claims. If code G0378 is reported more than once per 
claim, then edit 51 is applied and the claim is returned to the provider for correction. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospital services have not been met. Specifically, G0378 is reported twice on this claim. Therefore, 
OCE edit 51 applies and this claim is rejected to be returned to the provider for correction. Therefore, we 
decided that the Plan does not have to pay for outpatient hospital services provided from December 11, 2021, 
to December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refractive service (92015 TG) provided on May 3, 2022. 
 
You asked the Plan to pay for the vision care. You say that a mistake was made. You also say that this should 
be covered 100%. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the refractive service (92015 TG) provided on May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can be safely met by continuing in the hospital or in 
a skilled nursing facility once the enrollee's medical conditions are stable. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart 
failure. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The 
patient 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. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 268 units of ambulance mileage (A0425) billed for 
November 22, 2021. 
 
You asked the Plan to pay for 268 units of ambulance mileage. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan says this service was not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for codes with an MAI of 1, each line of a claim 
with that HCPCS/CPT code will be separately adjudicated against the MUE value for that code. A single line 
may not exceed the MUE for that code, but additional lines for additional units may be reported with an 
appropriate modifier. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1, which means that no more 
than 250 units may be reported on a single line for this service. You billed 268 units of this code on a single line, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay for 268 units 
of ambulance mileage (A0425) billed for November 22, 2021.
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 is being evaluated due to a recent 
positive COVID-19 diagnosis. You say that the enrollee needs skilled services. The Plan denied your request. 
The Plan says the enrollee does not meet the medical criterial for SNF admission. 
 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 based on the documentation provided, the enrollee does not qualify for SNF 
coverage. 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. Our reviewer also 
found that 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 ambulance services provided on March 16, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was already out of hospice at the 
time of transport. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator coded K0606 provided on 
May 1, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is missing a required modifier. 
 
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 K0606 is not supported in the medical record. Specifically, this code was billed 
modifiers RR (Rental), KI (Durable Medical Equipment, Prosthetics, Orthotics, & Supplies item, second or 
third month rental), and KX (services at and above the therapy caps). This means this code was billed with 
invalid modifiers for this item. Based on this information, we decided that Medicare rules for coverage of the 
automatic external defibrillator have not been met. Therefore, we decided that the Plan does not have to pay for 
the automatic external defibrillator coded K0606 provided on May 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fitness kit provided on March 16, 2022. 
 
You asked the Plan to pay for a fitness kit. You say that you were offered the fitness kit for free. You also say 
that you do not know about this program because you trusted the representative for your order. The Plan denied 
your request. The Plan says members who elect a home fitness kit that was not ordered from the Plan's mail 
order catalog will not be eligible to request for fitness reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that fitness benefits may be offered by Medicare 
Advantage plans as supplemental benefits designed to improve or maintain good health. Plans should describe 
specifically what is included in the supplemental fitness benefit. 
 
We looked at the file and Medicare rules. The fitness kit is not covered because you purchased the equipment 
from a different provider. Based on this information, we decided that Medicare rules for coverage of a fitness 
kit have not been met. Therefore, we decided that the Plan does not have to pay for a fitness kit provided on 
March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the 
Medicare guidelines defining criteria. The Plan denied your request. The Plan says admission to LTACH was 
denied as not meeting criteria, is not medically necessary, and continued care hospital stay was offered, until 
the enrollee 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 the LTACH services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the LTACH services.