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

 
We decided that the Plan does not have to pay for lab services (87481, 87798 and 87801) provided on July 1, 
2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records 
provided. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87481, 87798 and 87801) provided on July 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Peroral Endoscopic Myotomy. 
 
You asked the Plan to pre-approve Peroral Endoscopic Myotomy. You say that the records provided support 
the need for the requested services. The Plan denied your request. The Plan says scientific research has not 
established the requested procedures long-term effectiveness and improvement on outcomes when compared to 
standard therapy. 
 
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 Peroral Endoscopic Myotomy. Our 
reviewer says that Peroral Endoscopic Myotomy services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that the enrollee has an esophageal 
diverticulum. There is insufficient literature to support the safety and efficacy of the requested procedure for 
the enrollee's condition. The record provided does not establish the medical necessity and reasonableness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Peroral Endoscopic Myotomy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Peroral Endoscopic Myotomy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
vertebrogenic low back pain, spondylosis without myelopathy or radiculopathy, and intervertebral disc 
degeneration. The exam reveals lumbar pain elicited with range of motion in all planes. There are multiple 
plausible pathologic sources of the enrollee's significant pain generation. The back and hip pain, the noted pain-
aggravating factors (bending, twisting, range of motion, and lifting), pain-relieving factors (rest and laying 
down), and painful spinal motion (in all directions) were/are all non-specific to any pathologic entities. The 
Intracept procedure is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but still unstable for transfer and requires short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom g6 sensor. 
 
You asked the Plan to pre-approve a Dexcom g6 sensor. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member does not use insulin with at least three daily injections and 
requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
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 the enrollee does not use insulin 
with at least three daily injections and requires 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 Dexcom g6 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom g6 
sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01922 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 01922. You say that your records indicate that CPT code 01922 
is not inclusive to any other CPT on date of service April 18, 2022. CPT code 01922 is eligible for separate 
reimbursement. The Plan denied your request. The Plan says procedure code 01922 is considered bundled and 
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 procedure code. 
 We find that procedure code 01922 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 01922 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 01922 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 01922 billed for date of service April 18, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on January 10, 2022, to January 12, 
2022 at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says that the DRG is not supported. 
 
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 diagnosis code U07.1. 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 submitted records do not support the billing of diagnosis code U07.1. Our physician 
reviewer found the enrollee presented to the emergency department with positive COVID and decreased 
oxygen saturation. He had tested positive for COVID on a home test on January 3, 2022. He was admitted and 
treated with supplmental oxygen, Remdesivir, and intravenous (IV) steroids. The records support the billing of 
diagnosis code U07.1. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on January 10, 2022, to January 12, 2022 at the Diagnosis Related Group (DRG) 
originally billed.  
 
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 replacement flex-foot described by code L5980. 
 
You asked the Plan to pre-approve the L5980 prosthetic foot replacement. You say that the enrollee is not able 
to ambulate due to the damaged foot on their lower limb prosthesis. The Plan denied your request. The Plan 
says this is not covered as the enrollee's functional level is too low. 
 
The Plan must follow Medicare rules. Medicare rules say that the type of prosthetic foot described by code 
L5980 is only covered for enrollees at functional level 3 or higher. 
 
We looked at the file and Medicare rules. The documentation consistently states that the enrollee's functional 
level is 2. There is no evidence of a provider rating the functional level at 3 or above as required for the 
requested type of foot. Based on this information, we decided that Medicare rules for coverage of the L5980 
prosthetic foot replacement have not been met. Therefore, we decided that the Plan does not have to pre-
approve a replacement flex-foot described by code L5980.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic manipulative treatment (98940) and the office visit 
(99202) provided on July 20, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these services are not payable as they 
were rendered without prior authorization. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for these services by a contract provider. The file does not show that the Plan provided 
notice that these services would not be covered. Under Medicare rules, this means these services are considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the chiropractic manipulative 
treatment (98940) and the office visit (99202) provided on July 20, 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (E0466). 
 
You asked the Plan to pre-approve a non-invasive ventilator. You say that the device is needed for the enrollee. 
The Plan denied your request. The Plan says the requested device does not meet the requirements for approval. 
 
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 non-invasive ventilator. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has chronic 
respiratory failure consequent to COPD. The device is not necessary because the LCD states that products 
currently classified as HCPCS code E0466, when used to provide CPAP or bi-level PAP (with or without 
backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment 
category. A ventilator is not eligible for reimbursement for any of the conditions described in this RAD LCD 
even though the ventilator equipment may have the capability of operating in a bi-level PAP mode. Claims for 
ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not reasonable and 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 a non-invasive ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a non-invasive ventilator (E0466).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transportation provided on June 18, 2022. 
 
You asked the Plan to pay for air ambulance transportation. You say that these services were deemed medically 
necessary. The Plan denied your request. The Plan says there is no documentation that transportation by ground 
ambulance would endanger the enrollee's health. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transportation. Our reviewer 
says that this transportation does not meet criteria for payment. Our physician reviewer found the 
documentation does support that the enrollee suffered from an illness or injury that contraindicated 
transportation by any means other than ambulance. However, the documentation does not support that the 
enrollee's condition was such that the time needed for ground transportation, or instability of ground 
transportation, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance transportation provided on June 18, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupogen. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says a step therapy exception cannot be granted. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 drug. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the Plan 
requires a trial of Zarxio and Nivestym before they will approve the requested drug. In this case, the patient has 
not tried and failed the required drugs. There is no documentation provided indicating that the plans required 
drugs would likely be less effective and/or likely have adverse effects for the 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neupogen.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional power wheelchair accessories (K0108, E2311). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is no medical need to control the power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the accessories. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient is non-ambulatory from a functional perspective and requires a power wheelchair for 
mobility and performing her basic daily activities. She cannot perform pressure relief independently due to 
weakness and requires a power wheelchair with power tilt as well as a power articulating platform given her lower extremity lymphedema. The expandable controller is needed to operate and control the power options 
through the joystick. 
 
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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve additional power wheelchair accessories (K0108, E2311).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
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 
reviewer says that the services are medically necessary. Our physician reviewer found in an enrollee with 
radicular symptoms the administration of steroids provides a valid and recognized indication for lumbar MRI. 
The requested exam is 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.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge services (99239) billed for date of service 
February 2, 2022. 
 
You asked the Plan to pay for hospital discharge services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge services (99239) billed for date of service 
February 2, 2022.