Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on December 
28, 2021. 
 
You asked the Plan to pay for moderate sedation services. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
In this case, we find that CPT code 99153 was billed for an inpatient stay. It is not appropriate in this situation 
to separately report code 99153. Based on this information, we decided that Medicare rules for coverage of 
moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
moderate sedation services (99153) provided on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 16, 
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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom prosthetic protective cover (L5704). 
 
You asked the Plan to pre-approve the custom protective cover. You say that the protective cover is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer coverings are not for cosmetic or 
convenience reasons, or for everyday usage in a typical environment. 
 
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 custom protective cover. Our 
reviewer says that the requested protective cover is not medically necessary. Our physician reviewer found the 
provided records do not document that the enrollee is exposed to such harsh environments or conditions that 
the custom protective outer cover for the prosthesis meets Medicare criteria for medical necessity. 
 
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 custom protective cover have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a custom prosthetic protective cover (L5704).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from November 9, 2021, 
through December 31, 2021. 
 
You asked the Plan to pay for the acupuncture treatment. You say that the acupuncture treatment should be 
covered by the Plan. You say this provider has been practicing for twenty years and worked four years to 
obtain licensing and is the most respected practitioner in your area. The Plan denied your request. The Plan 
says an L.Ac. is not a Medicare authorized provider for the acupuncture for chronic low back pain benefit.  
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. 
 
We looked at the file, the Plans rules and Medicare rules. Based on this information, we decided that the rules 
for coverage of the acupuncture services have not been met. Specifically, there is no documentation that the 
acupuncture treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not 
document that the acupuncturist in this case was under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not 
have to pay for acupuncture treatment provided from November 9, 2021, through December 31, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish 
a safe and effective maintenance program. Your function was at or near your prior level of function and you 
could be discharged to a lower level of care for further 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
November 16, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. 
 
 
 
  
 Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies 
rendered on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (77062) provided on July 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 77062 is not valid for Medicare purposes. 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 (77062) provided on July 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current home setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
  
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning rendered on December 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 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 99497 
is a column II code to column I code 99223. 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 the advance care planning rendered on December 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health visits. 
 
You asked the Plan to pre-approve home health services. You say that you have had a nurse come to your 
house in the past. The Plan denied your request. The Plan says the provided documentation does not indicate 
that you are homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to an LTACH. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of thyroid 
cancer status post resection. The last CT scan in 2019 was negative. The physical exam on May 13, 2022 was 
negative for any abnormalities. There is no specific clinical rationale for the requested CT scan. The services 
are not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on September 14, 2021. 
 
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 diagnosis codes are not valid. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on 
September 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on August 
9, 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 a more appropriate code to use in this case. 
 
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 97110 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 
 
We find that CPT code 97110 is not supported in the medical record. Specifically [*****explain why code 
billed is not supported******]. 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 physical therapy 
services provided to the enrollee on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiopharmaceutical localization services provided on 
July 1, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there are no 
modifiers allowed with this code pair. 
 
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 78830 is a column II code to column I code 79101 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiopharmaceutical localization services provided on July 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you would like SNF care covered. The Plan denied 
your request. The Plan says there is no need for daily skilled therapy services to be provided by a skilled 
therapist on a daily basis and there are no daily skilled nursing needs. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do 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) admission and services.
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 your needs are custodial and can be met at a lower level of care. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testopel, 75 mg pellets, 12 pellets 900mg (J3490) every 
3 months. 
 
You asked the Plan to pre-approve Testopel. You say that the enrollee has previously taken this drug and has 
had great success in maintaining testosterone levels. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for approval for Testopel and the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Testopel. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the record indicates that the enrollee has a diagnosis of low testosterone secondary 
to Suboxone use. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug Compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Testopel have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Testopel, 75 mg pellets, 12 pellets 900mg (J3490) every 3 months.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on June 2, 2021. 
 
You asked the Plan to pay for the wound care services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says this was denied correctly and should be billed to the Original 
Medicare contractor. 
 
 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 the wound care services provided on June 2, 2021.