Persius/hicric huggingface dataset:
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 is medically stable to 
transfer to an LTACH at this time for daily physician visits for medical management, specialized ventilator 
weaning and access to physical, occupational, and speech therapy five times a week to promote strength and 
recovery. The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
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 that the enrollee is unstable and requires short-term additional acute care services that 
can safely be provided at the current facility until more stable for transfer. The enrollee does not require 
services at the LTACH that are not already available at the current facility.  
 
   
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the enrollee has had the best results and relief with 
this requested medication. You say that the enrollee has tried and failed Sanctura and Myrbetriq. The Plan 
denied your request. The Plan says this medication falls under Part D coverage. The Plan says that they do not 
administer Part D benefits for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  
 Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology services (88108) provided on August 1, 2022. 
 
You asked the Plan to pay for cytopathology services. You say that this service was reported correctly. The 
Plan denied your request. The Plan says this claim was submitted with an incorrect place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that, for a service rendered to a patient who is a 
registered inpatient or an outpatient of a hospital, the appropriate POS code is that of the appropriate inpatient 
or outpatient code which reflects the enrollees status regardless of where the face-to-face service occurs. 
 We looked at the file and Medicare rules. The record shows that at the time of services, the enrollee was 
inpatient status at the hospital. However, this service was billed with POS code 22  On Campus-Outpatient 
Hospital. Based on the enrollees status at the time of services, this claim should have been submitted with an 
inpatient POS code. Based on this information, we decided that Medicare rules for coverage of cytopathology 
services have not been met. Therefore, we decided that the Plan does not have to pay for cytopathology 
services (88108) provided on August 1, 2022.
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 requires aggressive physical, 
occupational, and speech therapy due to their current illness. You say that the enrollee will also require daily 
doctor visits by a specialized physician such as a pulmonologist which can be managed at an LTACH level of 
care. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the 
enrollee can receive the care they need in current hospital 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 that the enrollee is more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from June 4, 
2022, to July 3, 2022.  
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the admit date was submitted incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The admit date is in 2021. For enrollees receiving services in 2021 that continue into 2022, the home health 
agency must submit a Notice of Admission (NOA) with a one-time artificial "admission" date corresponding 
the "from" date of the first period of continuing care in 2022. 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 home health services provided to the enrollee from June 4, 2022, to July 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from July 2, 
2021, to July 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is missing information. 
 
The Plan must follow Medicare rules. Medicare rules say that certain data elements are required for home 
health services. 
 
The claim was not submitted with valid G and Q codes. 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 home health services provided to the enrollee from July 2, 2021, to July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-ray rendered on July 28, 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 claim has not been processed by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan 
requested the Explanation of Benefits (EOB) for this claim from the primary insurer on September 30, 2022, 
and October 7, 2022 and did not receive a response. As the secondary insurer, the Plan cannot be held 
responsible for these services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the office visit and x-ray rendered on July 28, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an IRF admission to facilitate 
increased independence and return home. The Plan denied your request. The Plan says that admission to an IRF 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that clinical documentation shows that the enrollee has complex functional impairments with 
neurological weakness related to myelopathy. Evaluating therapists recommend an intense therapy regimen in 
an IRF setting. Clinical documentation with the appeal letter shows that the enrollee is at risk for spinal cord 
injury complications and other active medical comorbidities thus, this enrollee would be expected to require 
continued inpatient hospitalization during rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
the IRF admission and services.  
 
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 a sacroiliac joint arthrodesis (27279). 
 
You asked the Plan to pre-approve a sacroiliac joint arthrodesis. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sacroiliac joint arthrodesis. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures, including medication optimization, 
activity modification, bracing and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip, 
including a home exercise program. Additionally, the documentation does not demonstrate 3 positive 
provocative test findings. The sacroiliac joint injection provided on December 13, 2022, was noted to have 
provided zero benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sacroiliac joint arthrodesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint arthrodesis (27279).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee is requiring greater 
than 3 nights in the hospital due to findings of significant high ostomy output concern of significant recurrence 
of acute kidney injury and dehydration as well as malnutrition until this is properly corrected. The Plan denied 
your request. The Plan says the acute inpatient hospital services do not appear medically necessary. The 
enrollee did not require intervention such as dialysis, corticosteroids, or renal biopsy. Rather, the enrollee 
responded promptly to intravenous fluid and enteral feedings. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care has been met 
in this case. Our physician reviewer found the enrollee was readmitted the day after being discharged due to 
home care services were not properly arranged for enteral feedings, as she did not have any tube feeding 
supplies or enteral foods at home. She was treated for acute kidney injury secondary to dehydration, and 
promptly responded to intravenous fluid hydration and enteral feedings. The enrollee remained clinically stable 
while arrangements for a safe discharge were pursued. The review has determined that the record showed that 
at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on May 25, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) provided on 
May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 and drug testing 
billed with code 80307 for date(s) of service June 20, 2022. 
 You asked the Plan to pay for the lab services. You say that this service is medically necessary and should be 
paid. The Plan denied your request. The Plan says code 83789 is not separately payable. The Plan also says the 
documentation is not sufficient to verify the billed code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. Medicare rules also 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 Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Additionally, we decided that there is insufficient information in the record to determine if 
Medicare rules for coverage of code 80307 have been met. There is no lab report showing results of a 
presumptive drug test. 
 
Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 and drug 
testing billed with code 80307 for date(s) of service June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-segmental pneumatic half leg pneumatic 
appliance (E0666) and a segmental gradient pressure pneumatic appliance (E0673) for use with a pneumatic 
compression device (E0676). 
 
You asked the Plan to pre-approve accessories to a pneumatic compression device represented by code E0676. 
You say that the clinical documentation provided supports the need for the requested items. The Plan denied 
your request. The Plan says the items in dispute are non-covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the pneumatic compression device that the requested 
accessories would be used with is not a covered benefit of Medicare or the Plan. PCDs are not covered for 
preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve a non-segmental 
pneumatic half leg pneumatic appliance (E0666) and a segmental gradient pressure pneumatic appliance 
(E0673) for use with a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) of the upper right and lower left 
quadrant provided on August 9, 2021. 
 
You asked the Plan to pay for gingival irrigation (D4921). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this is not covered under your current plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) of the upper right and lower left quadrant provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the transitional care management services (99495) provided on May 25, 
2022. 
 
You asked the Plan to pay for the transitional care management services. You say that this claim should be 
reprocessed and approved for payment. The Plan denied your request. The Plan says that payment for 
transitional care management services cannot be considered until a qualifying facility claim is received. 
 
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. In this case, the Plan has not fully substantiated their denial. Although the Plan 
states that this claim cannot be considered until a qualifying facility claim is received, this is not supported by 
Medicare rules. At most, a discharge summary is needed which shows when the enrollee was discharged to 
make sure that the timing meets the code criteria. This summary supports the services as billed. Therefore, we 
decided that the Plan has to pay for the transitional care management services (99495) provided on May 25, 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve therapeutic parenteral drug-single administration (code D9610). 
 
You asked the Plan to pre-approve therapeutic parenteral drug-single administration (code D9610). You say 
that therapeutic parenteral drug-single administration (code D9610) is medically necessary. The Plan denied 
your request. The Plan says that therapeutic parenteral drug-single administration (code D9610) is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 therapeutic parenteral drug-single 
administration (code D9610). Our reviewer says that the requested therapeutic parenteral drug-single 
administration (code D9610) is considered medically reasonable and necessary in this case. Our physician 
reviewer found \that the administration of the therapeutic parenteral drug (code D9610) meets the criteria of 
medically reasonable and necessary for the management and treatment of undergoing general anesthesia for 
surgical dental procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic parenteral drug-single administration (code D9610) have been met. 
Therefore, we decided that the Plan has to pre-approve therapeutic parenteral drug-single administration  
(code D9610).  
 
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.