Persius/hicric huggingface dataset:
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 the enrollee needs IRF care. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5105). 
 
You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says drugs that are dispensed to the physician by a 
pharmacy are not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Retacrit (Q5105).
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 the services are necessary for the enrollee to improve 
their strength and endurance. The Plan denied your request. The Plan says ongoing skilled care can be provided 
in an alternative setting. 
 
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 enrollee does not require treatment by multiple therapies. Currently the enrollee 
requires moderate to maximum assistance with daily activities, mobility, and transfers. The enrollee has had a 
decline from their baseline level of function and would likely benefit from therapy, but they do not require the 
intensity of therapies provided on acute inpatient 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on October 26, 2022. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you disagree with the Plan's denial. 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 the Guardant360 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing 
provided on October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on December 27, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on 
December 27, 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 the enrollee has had improvement during their 
hospital stay, however has left them at a functional status below their baseline and require close daily oversight 
of care by a physician in an inpatient setting along with specialized psychiatry care. The Plan denied your 
request. The Plan says the request is not medically necessary, the services the enrollee needs can be provided 
safely in other settings, for example, a skilled nursing facility. 
 
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 a urine polymerase chain reaction (PCR) panel rendered on 
June 25, 2020. 
 
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 this is considered unproven and 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the standard for diagnosing a urinary tract infection is a bacterial urine culture performed on a urine 
specimen to establish the probable etiology of a presumed urinary tract infection. It is common practice to do a 
urinalysis prior to a urine culture. The PCR testing is considered unproven and not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a urine polymerase chain reaction (PCR) panel rendered on June 25, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a home sleep test (HST) with type III portable monitor (G0399). 
 
You asked the Plan to pre-approve an HST. You say that the enrollee is interested in treatment with other 
possible modalities, but given the length of time since the last sleep study, a new sleep study is needed to 
determine the best treatment. The Plan denied your request. The Plan says that the requested service is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Type II or Type III sleep testing devices are covered 
when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of 
OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. 
 
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 HST. Our reviewer says that a home 
sleep study is considered reasonable and medically necessary for this enrollee. Our physician reviewer found 
this enrollee has mild OSA, diagnosed on a home sleep test in 2012. The enrollee subsequently had a positive 
airway pressure (PAP) titration study, and was started on continuous positive airway pressure (CPAP). Our 
reviewer found that the enrollee was unable to tolerate the CPAP mask because of anxiety, they continue to be 
symptomatic from OSA, and now returns wanting to consider other treatment alternatives. If this enrollee's 
OSA continues to be mild, a mandibular advancement device may be a consideration. Our physician reviewer 
found that it is reasonable to repeat the home sleep study to reassess the severity of the OSA, especially since 
the original sleep study in 2012 had less than 4 hours of sleep time. Our reviewer also found that repeating a 
sleep study will help to determine whether an oral device is a reasonable approach for this enrollee. 
 
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 HST have been met. Therefore, we decided that the Plan has to pre-approve 
a home sleep test (HST) with type III portable monitor (G0399).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on October 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit".  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99223 is 
not supported by the records provided. Our reviewer found that the documentation available for review does 
not support the encounter required decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99223) provided on October 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission will affect the enrollee's ability to 
regain maximum function. You would like reconsideration based on the records submitted. The Plan denied 
your request. The Plan says the requested IRF admission 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for non-surgical management of a pelvic fracture after a fall. The enrollees medical 
problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the enrollee may have a need for physical therapy 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 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neurophysiological testing (95955, 
G0453). 
 
You asked the Plan to pay for the intraoperative neurophysiological testing. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the intraoperative neurophysiological testing may be 
covered when the criteria listed in Medicare Rules section 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 pay for the intraoperative neurophysiological 
testing. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation does not sufficiently support that there was risk of cerebral ischemia during surgery of the aortic 
arch, its branch vessels, or thoracic aorta, including internal carotid artery surgery. 
 
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 intraoperative neurophysiological testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the intraoperative neurophysiological testing (95955, G0453).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99283) provided on August 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99283) is included in the global 
surgery payment for the procedure (G0168) provided on the same date of service. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pay for the services (99283) provided on August 18, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is confused and it is not safe to return 
home. The Plan denied your request. The Plan says that the denial of SNF care is correct. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has stabilized and is ready for discharge from the hospital. Although the 
enrollee does not have skilled nursing needs, the enrollee has significant decline in physical functioning. The 
enrollee does require skilled therapy services on a daily basis at a skilled nursing facility to restore function and 
avoid further decline or complications. Admission to SNF for inpatient rehabilitation services is medically 
appropriate. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number 
of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest with 
contrast (71260). 
 
You asked the Plan to pre-approve a CT scan of the chest with contrast. 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. Medicare rules say that CT scans 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 a CT scan of the chest with contrast. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found no abnormal 
findings were noted on physical exam and labs were ordered. No Chest x-ray was obtained. There is no clinical 
rationale for the requested chest CT scan with contrast. 
 
   
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 CT scan of the chest with contrast have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest with contrast 
(71260).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service June 8, 
2022. 
 You asked the Plan to pay for procedure code 0003A. You say that this claim should be paid. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service June 8, 2022.