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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that radiofrequency ablation 
to the SI joint is medically necessary. The Plan denied your request. The Plan says the requested 
radiofrequency ablation to the SI joint is 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 radiofrequency ablation to the SI joint. 
Our reviewer says that the requested radiofrequency ablation to the SI joint is not considered medically 
reasonable and necessary. Our physician reviewer found that radiofrequency ablation of the lateral sacral 
branches is considered experimental/investigational because of the wide variation in efficacy reported in the 
literature. Therefore, the request is deemed not medically 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel (87503, 87632, 87634) provided on 
June 17, 2022. 
 
You asked the Plan to pay for the respiratory panel. You say that these services should be covered. The Plan 
denied your request. The Plan says respiratory panels should not be unbundled. Additionally, the Plan says that 
procedure code 87634 is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. A respiratory pathogen panel test must not 
be unbundled and billed as individual components regardless of the fact that the panel reports multiple 
individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. We find that procedure code 87634 has a Status Indicator of I on the 
Physician Fee Schedule. This means that procedure code 87634 is not valid for Medicare purposes. 
Additionally, respiratory testing must not be unbundled. Procedure codes 87503and 87632 have been billed as 
individual components rather than as part of the panel. Based on this information, we decided that Medicare 
rules for coverage of the respiratory panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the respiratory panel (87503, 87632, 87634) provided on June 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care provided from July 10, 2022, 
through July 14, 2022. 
 
You asked the Plan to pay for inpatient psychiatric care. You say that the enrollee's coverage termed on 
December 31, 2021. The Plan denied your request. The Plan says the enrollee has another insurance carrier as 
primary with an effective date of January 1, 2022. 
   
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for inpatient 
psychiatric care until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for inpatient psychiatric care provided from July 10, 2022, through July 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria has not been met. 
 
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 drug is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has age related osteoporosis without osteoporotic fracture.  The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would 
have an adverse effect from the plan's preferred step one alternative. 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit provided from February 2, 2022, to 
June 20, 2022. 
 
You asked the Plan to reimburse you for the evaluation and management services. You say that you have paid 
these claims in full. You also say that you should be reimbursed. The Plan denied your request. The Plan says 
the provider in this case is not enrolled in Medicare. The Plan also says that payment cannot be made for 
services performed by a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the office visit provided from 
February 2, 2022, to June 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 14, 2022, to 
May 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 14, 2022, to May 
13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed with side-rails. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you are sleeping on a chair and 
can no longer do that as it is causing you pain. The Plan denied your request. The Plan says your medical 
condition does not describe a history of congestive heart failure, chronic pulmonary disease, or problems with 
aspiration is medically necessary. Clinical notes do not show that frequent repositioning is required or that the 
head of the bed must be elevated above 30 degrees due to a medical condition such as congestive heart failure, 
chronic pulmonary disease, or problems with aspiration. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found provided records 
document you have difficulty lifting yourself onto your ordinary bed. Provided records do not document you 
require frequent changes in body position or immediate changes in body position. Although side rails are 
requested, provided records do not document your condition requires special attachments that cannot be fixed 
and used on an ordinary bed. The semi-electric hospital bed does not meet all coverage criteria. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed with side-rails.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a COBRA scooter (K0812). 
 
You asked the Plan to pre-approve a COBRA scooter. You say that you are requesting a COBRA scooter 
because you wanted to have a mobility device delivered sooner. The Plan denied your request. The Plan says a 
Group 2 heavy duty powered operated vehicle (scooter) has already been approved and was delivered on 
November 21, 2022. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have Group 2 heavy duty powered scooter. Group 2 heavy duty powered scooter serves 
the same purpose as a COBRA scooter. Therefore, we decided that the Plan does not have to pre-approve a 
COBRA scooter (K0812).
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 need the inpatient rehab so you can regain your 
ability to walk. You say that you are doing physical therapy and are making improvements. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary, and you can safely receive the 
services you need in other settings. 
 
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 you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You can receive further services at a 
lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous thermal intradiscal (Intracept) procedure 
(64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
those that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says the requested 
procedure is 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental. Therefore, the reviewer found 
that an Intracept procedure is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a percutaneous thermal intradiscal (Intracept) procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640, 87653, 87651, 87500, 87150, 87798 
and 87481 billed for date of service April 21, 2022. 
 
You asked the Plan to pay for procedure codes 87640, 87653, 87651, 87500, 87150, 87798 and 87481. You say 
that these services were billed correctly. The Plan denied your request. The Plan says the use of the 59 modifier 
is not supported for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 87640, 87653, 87651, 
87500, 87150, 87798 and 87481 have been met. Specifically, the records provided do not include a physician 
order to verify the procedures requested. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87640, 87653, 87651, 87500, 87150, 87798 and 87481 billed for date of service April 21, 
2022.
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 
August 23, 2021, to August 28, 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 DRG was updated.  
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 175. 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 the review has determined that the records do not support DRG 175 or DRG 176 in this case. The records 
do not support the diagnosis of E43 (unspecified severe protein-calorie malnutrition) in this case. Protein 
calorie malnutrition (PCM) is the state of inadequate intake of food (as a source of protein, calories, and other 
essential nutrients) occurring in the absence of significant inflammation, injury, or another condition that elicits 
a systemic inflammatory response. in this case there was no clinical or laboratory evidence for PCM.  
 
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 August 23, 2021, to August 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, 
E2359, K0108, E1028, E2377, E2313, E1007, E2311, E2620, E2624, E1012, E0953, E0990, E0960, E0956, 
E0957, E0955). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollee currently uses a 
power wheelchair and was recommended for a group 2 power wheelchair by the evaluating therapist. The 
enrollee does not meet coverage criteria for a group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair and accessories (K0861, E2359, K0108, E1028, E2377, E2313, E1007, E2311, 
E2620, E2624, E1012, E0953, E0990, E0960, E0956, E0957, E0955).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 15, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied with code G and code B 
provided ot the enrollee from February 4, 2022, to February 24, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the remaining charges were denied for unbundling and lack of documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that after a careful review of the 
additional charges and the medical records, the documentation does not meet the criteria. Denying the charges 
for unbundling was correct, as the services billed are routine and would be included in the daily charges. The 
services were improperly unbundled from the critical care services provided. Additionally, there is no 
documentation of the specific services denied for a lack of documentation. These charges cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services denied with code G and code B provided ot the enrollee from 
February 4, 2022, to February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a back-up manual wheelchair. 
 
You asked the Plan to pre-approve repairs to a back-up manual wheelchair. You say that you need a new 
rubber, or two new wheels put on the wheelchair so you can go to your doctor's appointments. The Plan denied 
your request. The Plan says repairs to a backup wheelchair are not covered. Records show your primary manual 
wheelchair was recently repaired. 
 
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. Repairs to a backup wheelchair are not a covered benefit with your 
Plan. Based on this information, we decided that Medicare rules for coverage of repairs to a back-up manual 
wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs to a 
back-up manual wheelchair.