Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous passive motion device (E0936) provided 
January 27, 2022 to March 7, 2022. 
 
You asked the Plan to pay for the continuous passive motion device. You say that this device was medically 
necessary and should be covered. The Plan denied your request. The Plan says this device is only covered for 
patients who have received a total knee replacement. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pay for 
a continuous passive motion device (E0936) provided January 27, 2022 to March 7, 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 you are appealing the authorization of denial of 
inpatient rehabilitation facility admission.  The Plan denied your request. The Plan says the clinical 
documentation from the doctor does not show that you will be able to participate in 3 hours of intensive 
therapy, 5 days a week. 
 
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 were admitted for a stroke. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While you have 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 acute IRF admission and services.
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 you are requesting an expedited appeal. The Plan 
denied your request. The Plan says it has been determined that the services are 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 the enrollee was admitted for surgical management of an abdominal abscess.  
Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 While the enrollee has 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 acute IRF admission and services.
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 you are appealing the denial of authorization for 
acute inpatient rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollee's condition they 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 the enrollee was admitted for a stroke. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  While the enrollee has 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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87640, 87641, 87653, and 
87798 billed for date of service August 16, 2021. 
 You asked the Plan to pay for procedure code 87150, 87481, 87640, 87641, 87653, and 87798. You say that 
you disagree with the denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, 
87640, 87641, 87653, and 87798 is bundled into payment for other codes. 
 
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 87150 
is a column II code to column I code 87500 and codes 87481, 87640, 87641, 87653, and 87798 are column II 
codes to column I code 87801. 
 
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 
procedure codes 87150, 87481, 87640, 87641, 87653, and 87798 billed for date of service August 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found the review has determined that 
the requested use of Euflexxa is not FDA-approved for the enrollees diagnosis. Its use is not supported by one 
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  The 
documentation does not support that the Euflexxa is medically reasonable or necessary 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing provided on October 26, 2021. 
 
You asked the Plan to pay for diagnostic testing. You say that the operating surgeon calls your company in to 
provide ancillary neurodiagnostic services for the safety and protection of the enrollee. You also say that you 
provide the service in its entirety and do not have a contract to bill the facility. The facility cannot bill for 
services. You would like the Plan to reconsider the claim for payment. The Plan denied your request. The Plan 
says the charge is included in the facility benefit. The Plan also says you should bill the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of diagnostic testing have not been met. Specifically, payments for TCs are included in the payment 
to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does 
not have to pay for diagnostic testing provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and power 
accessories (E2300, E2363, E1002, E2311, E1012, E0955, E1028x2, E2377, E2313, E2601). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and power accessories. You say that the 
requested DME is medically necessary. The Plan denied your request. The Plan says you do not meet medical 
criteria for the requested power wheelchair and accessories. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 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 group 3 power wheelchair and power 
accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found there 
is no documentation that you meet Medicare criteria for the requested group 3 power wheelchair and power 
accessories. Provided records do not document you are high risk for a pressure ulcer with a reported Braden 
scale score of 17. Records do not document that you perform intermittent catheterization for bladder 
management or that you have increased muscle tone or spasticity. Thus, you do not meet criteria for the 
requested single power option and none of the requested accessories are covered. A group 3 power wheelchair 
with no power option appears indicated in this case. 
 
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 group 3 power wheelchair and power accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and 
power accessories (E2300, E2363, E1002, E2311, E1012, E0955, E1028x2, E2377, E2313, E2601).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tepezza. 
 
You asked the Plan to pre-approve Tepezza. You say that the enrollee responded well after the first treatment 
of Tepezza, but their condition has progressed. The Plan denied your request. The Plan says a repeated series of 
Teprotumumab must be considered experimental and investigational. 
 
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 Tepezza. Our reviewer says that the 
documentation does not support that a repeat series of Tepezza infusions is medically reasonable and necessary 
for the enrollee. Our physician reviewer found the documentation does not support that Tepezza is safe and 
effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tepezza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tepezza.
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 continuation of SNF care is medically necessary. 
The Plan denied your request. The Plan says authorization denied for continued SNF care because the enrollee's 
illness has improved and their wound care can be managed at a lower level of care, such as home with health 
care services. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the enrollee no longer qualifies for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
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 pre-approve a RestoreX device. 
 
You asked the Plan to pre-approve a RestoreX device. You say that the requested item is a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a RestoreX device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain 
(70553). 
 
You asked the Plan to pre-approve an MRI of the brain. The Plan denied your request. The Plan says it is not 
medically necessary for the enrollee to receive a brain MRI. 
 
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 brain. Our reviewer says 
that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has had a lot of mucous in their throat in the mornings for many years, but there are no other imaging 
studies that report abnormal findings and need clarification. 
 
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 brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the brain (70553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 17, 2022 billed with 
codes 0031U, 81225, 81226, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, 81355, 81406, and 
81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 17, 2022 billed with codes 0031U, 81225, 81226, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 
81335, 81355, 81406, and 81407.
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 your doctor says you need additional rehabilitation 
care provided in an IRF. 
 The Plan denied your request. The Plan says the criteria for admission to an IRF are not met in this case. 
 
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. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in portable whirlpool tub. 
 
You asked the Plan to pre-approve a walk-in portable whirlpool tub. You say that this is medically necessary. 
The Plan denied your request. The Plan says that this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in portable whirlpool tub.
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 enrollee requires aggressive long 
term hospital services and transfer to an LTACH is medically necessary. The Plan denied your request. The 
Plan says the criteria for admission to an LTACH are not met in this case. The services the enrollee needs can 
be provided in an alternate setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was admitted to the acute care hospital with chronic obstructive 
pulmonary disease (COPD) exacerbation and pneumonia complicated by sepsis requiring intravenous (IV) 
antibiotics, breathing treatments, BiPAP (bilevel positive airway pressure) and oxygen support. Recent notes 
describe the enrollee as now on high flow oxygen support and requiring additional IV antibiotics. The enrollee 
appears to be more stable and improving with current treatment and should only require short-term additional 
acute care services that can safely be administered at the current facility until more appropriate for a lower level of care. The enrollee does not require services at the LTACH 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 at 
this time. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 9, 2022 billed with 
codes 81194, 81301, 81455 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 9, 2022 billed with codes 81194, 81301, 81455 and 81479.