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

 
We decided that the Plan does not have to pre-approve a biopsy to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a biopsy to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a biopsy to be provided by an out-of-network (OON) 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 need IRF care. The Plan denied your request. 
The Plan says you do not meet criteria for IRF coverage. 
 
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 you are medically stable and do not need a physical medicine and rehabilitation 
physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no nursing needs documented. At your current 
functional level, you do not need 3 hours a day for 5 days a week of therapies with multidisciplinary approach 
in an IRF. While you may benefit from physical therapy and occupational therapy, your rehabilitation needs 
can be safely met in an alternate and low intensity 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for CGMs and related 
supplies have not been met. 
 
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 you do 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 CGM and related supplies 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (CGM) and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 18, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87532 and 87496 billed for date of service 
January 5, 2022. 
 
You asked the Plan to pay for procedure codes 87532 and 87496. You say that these services were reported 
appropriately. The Plan denied your request. The Plan says the documentation provided does not support the 
reporting of these services. 
 
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 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 procedure codes 87532 and 87496. Our reviewer says that 
these services are not supported in the medical record. Our reviewer found the documentation provided does 
not include the results of these tests; therefore, it cannot be verified that they were performed. 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87532 and 87496 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87532 and 87496 billed for date of service January 5, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0009 billed for date of service March 15, 2022. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says that the rules for 
payment have not been met. 
 
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 G0009 is administration of pneumococcal vaccine. We 
find that code G0009 was denied as it was not billed with a 771 revenue code. The claim information shows 
that the services were provided at a rural health clinic. Revenue code 771 is billed for all providers except 
RHCs and FQHCs. Based on this information, we decided that Medicare rules for coverage of the billed service 
have been met. Therefore, we decided that the Plan has to pay for procedure code G0009 billed for date of 
service March 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced foot/microprocessor foot. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a request for K3 microprocessor foot does not meet Medicare criteria for being 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot.  
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is evidence of a benefit for the microprocessor system. The enrollee is a K3 level ambulator. 
The plan has not addressed the specific reasons for why this system is not medically necessary, given your 
history of falls and difficulty negotiating stairs. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve an advanced foot/microprocessor foot.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that bilevel positive airway pressure (BiPAP) 
therapy's flow capability is limited, and use of this therapy would be detrimental and life threatening to the 
enrollee's condition. You say that the requested home ventilator with dual modes allows treatment of the 
enrollee in the home and helps avoid hospitalization. The Plan denied your request. The Plan says the requested 
device would be used in BiPAP mode that could be provided with a BiPAP device with average volume-
assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary.  This enrollee has severe chronic obstructive pulmonary disease (COPD.)  However, there 
is no documentation of chronic carbon dioxide (CO2) retention with arterial blood gas (ABG) done while 
stable.  If the enrollee does have chronic CO2 retention, they may benefit from BiPAP with AVAPS during 
sleep. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on December 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support the need for 
the services in dispute. The Plan denied your request. The Plan says that the requested testing is not approved 
by the Food and Drug Administration (FDA) as a companion in vitro diagnostic. The Plan says that the enrollee 
does not have an FDA approved or cleared indication for use in the type of cancer they have. 
 
The Plan follows Medicare rules. Medicare rules say that NGS testing is covered for certain medical 
indications.  
 
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 laboratory services. Our reviewer says 
that the criteria for coverage have been met. Our physician reviewer found the records show that the laboratory 
service in dispute was next generation sequencing. The records show that the enrollee has an advanced 
metastatic somatic cancer (urothelial). The records show that the enrollee had not yet completed this testing. 
The testing in dispute is considered further treatment for the enrollee's cancer and is considered 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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for laboratory services provided on December 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nail debridement (11720) provided on 
March 29, 2022, and June 15, 2022. 
 
You asked the Plan to waive the copayment for nail debridement. You say that you did not have a copayment 
in the past. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for podiatry services.  
 
You have been asked to pay a $24.62 copayment for each nail debridement because the allowed amount for 
these services is less than $30 dollars. Nail debridement falls within the podiatry services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for nail debridement (11720) provided on March 29, 2022, and 
June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression devices (E0651, E0669) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compression devices (E0651, E0669) to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services to help gain strength 
and independence. The Plan denied your request. The Plan says the request 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 2, 2021, to December 18, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the provider reported DRG 682. A review of 
the records instead supports DRG 640. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 682. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, there was no clinical evidence of acute renal failure. The review has determined that DRG 
640: MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND 
ELECTROLYTES WITH MCC is appropriate. The records did not support a diagnosis of N17.0 - acute kidney 
failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 2, 2021, to December 18, 2021.
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 dire need of therapy and an IRF would 
provide more therapy daily. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested IRF services do not meet the requirements for approval. 
 
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 your 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 you 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. The Plan denied your request. The Plan says 
that this request cannot be approved because the records do not show results of a face-to-face workup 
(evaluation) that support the requested study. The Plan also says that the enrollee has not completed six weeks 
of provider directed treatment, the provider directed treatment did not occur within the last three months, and 
there was no contact with the provider after completing treatment. 
 
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 an MRI of the lumbar spine. Our 
physician reviewer found the enrollee has a long history of back pain. An MRI in 2020 showed multilevel 
degenerative changes and stenosis, and two epidural steroid injections (ESIs) were performed with some relief. 
Our reviewer found that the enrollee has had recent exacerbation of symptoms and was seen in September 
2022, when they were diagnosed with likely sacroiliac joint dysfunction and a steroid injection was performed. 
The enrollee still has symptoms and desires the MRI of the lumbar spine for planning of lumbar ESI. 
According to plan rules medical necessity is established if the enrollee has steroid injections and no relief. Our 
physician reviewer found that this is true in this case, and the notes indicate not only was the enrollee seen face 
to face in September 2022, but also had a steroid injection. Our reviewer also found that the exam is thus 
considered 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 an MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).  
 
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.