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

 
We decided that the Plan does not have to pre-approve an advanced prosthetic foot system. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the request 
exceeds the enrollee's needs. The Plan follows Medicare rules. Medicare rules say that lower limb prostheses is only covered under certain 
medical conditions.  
 
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 requested item. Our physician 
reviewer found that the enrollee's functional activities include residential walking, meal prep, watching TV, 
personal hygiene and driving. Variable cadence activities include exercise (yoga, aerobics) and long walks. 
Foot justification notes walk farther with reduced weight, increased stability, provide for increased activity, 
walk on uneven ground, variable cadence. The requested foot system exceeds the enrollees medical needs. The 
documentation does not reveal objective physician medical progress reports supporting the prosthetist's 
(vendor) documentation that the enrollee is at a K3 level and requires a flex walk foot system. 
 
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 requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an advanced prosthetic foot system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Paclitaxel. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, and Paclitaxel. 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 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 Keytruda, Carboplatin, and Paclitaxel. 
Our reviewer says that the medication is not medically necessary. Our physician reviewer found this 
combination is not medically reasonable and necessary or safe and effective 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 Keytruda, Carboplatin, and Paclitaxel have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Keytruda, Carboplatin, and Paclitaxel.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs and had wound care to multiple ulcers. The enrollee was at a maximal assist 
level with functional mobility. The enrollee does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 22, 
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 these services are inclusive to other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 75822 and 75825 is not supported in the medical record. Specifically, both of these 
codes are considered inclusive to CPT 37238. It would not be appropriate to report these services separately. 
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 imaging services provided to the enrollee on 
November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract saying that these lab 
services are included in the payment to the dialysis facility. The Plan denied your request. The Plan says 
payment for these lab services is bundled into payment made to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System base rate and must be reported by 
the ESRD facility and are not separately paid.  This rule applies regardless of your contract status with the 
ESRD facility. 
 
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. Therefore, we decided that the Plan does not have to pay for lab 
services provided on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 13, 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 the denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 14060: 
 
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less 
 
CPT 15004: 
 
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including 
subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 
 
CPT 15733: 
 
Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, 
genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) 
 
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 in terms of CPT 14060, the operative 
report describes undermining, and does not support adjacent tissue transfer. In terms of CPT 15004, the 
operative report describes preparation of a recipient site. The documentation describes minimal debridement, 
and therefore cannot be verified. In terms of CPT 15733, the operative report does not include enough 
documentation to confirm (per NCCI Policy Manual) the full description of CPT 15733 has been performed, to 
include a names vascular pedicle, in this case. 
 
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 surgical services provided to the enrollee on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract saying that these lab 
services are included in the payment to the dialysis facility. The Plan denied your request. The Plan says 
payment for these lab services is bundled into payment made to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System base rate and must be reported by 
the ESRD facility and are not separately paid.  This rule applies regardless of your contract status with the 
ESRD facility. 
 
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. Therefore, we decided that the Plan does not have to pay for lab 
services provided on October 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you still need to get stronger after your stroke. The 
Plan denied your request. The Plan says IRF care is not medically necessary and you can be managed 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 the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for a stroke with right sided weakness. Your medical problems are stable and you have no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TransCranial Magnetic Stimulation (TMS) services. 
 
You asked the Plan to pre-approve TMS services. You say that the records provided support the need for TMS 
services. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the order for TMS treatment (or retreatment) 
must be written by a psychiatrist (MD or DO) who has examined the patient and reviewed the record and that 
the treatment needs to be given under direct supervision of this physician. 
 
We looked at the file and Medicare rules. The records show that the order for TMS was made by a primary care 
physician and that the treatment would be performed by a neurologist. Based on this information, we decided 
that Medicare rules for coverage of TMS services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve TransCranial Magnetic Stimulation (TMS) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a folding walker provided to the enrollee on July 20, 2021. 
 
You asked the Plan to pay for this walker. You say that this claim should be paid. The Plan denied your 
request. The Plan says there is not a valid physicians order, and the prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to prior authorization. The contract with the Plan says that 
durable medical equipment requires prior authorization.  In addition, there is not a valid physician order submitted with the claim. Therefore, we decided that the Plan 
does not have to pay for a folding walker provided to the enrollee on July 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot walk and are at a high risk of falling. The 
Plan denied your request. The Plan says you do not require IRF care and you can be managed 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical 
history of transient ischemic attack and are living at home with weakness and functional decline despite home 
health services. Your medical problems are stable and you have no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary care provider (PCP) services with an out of 
network (OON) provider. 
 You asked the Plan to pre-approve PCP services with an OON provider. You say that the requested provider 
has been your PCP for many years. You say that you are in excruciating pain. The Plan denied your request. 
The Plan says the requested provider is not uniquely qualified to treat the enrollee's medical conditions. The 
Plan say that the required services can be provided by a contracted provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 PCP services with an OON provider. 
Our reviewer says that the criteria for OON coverage have not been met. Our physician reviewer found the 
enrollee has multiple medical issues and must go get testing done often. The OON provider has been her 
primary care physician for many years. However, this provider is not contracted with her current health plan, 
which she enrolled in effective January 1, 2022. The enrollee indicated they cannot find a local in-network 
PCP. She is in excruciating pain and cannot sleep and has been to the emergency room twice. There is no 
specific clinical rationale for continued care with the OON provider. The review has determined that the 
requested provider is not uniquely qualified to treat the enrollee's medical conditions. The Plan states that the 
required services can be provided by a contracted provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PCP services with an OON provider have not been met. Therefore, we decided 
that the Plan does not have to pre-approve primary care provider (PCP) services with an out of network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care will be better for providing your care. You 
want to leave the current skilled nursing facility (SNF) facility and if sent home you will be at risk of fall. You 
claim you are not getting your medical needs met at current facility. The Plan denied your request. The Plan 
says you do not require an IRF 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 you are medically stable and do not need physician close supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. No rehab nursing needs have been identified or documented in the record. You do not need 
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. 
While you may benefit from therapy, your rehab can be safely provided and continued at a lower intensity and 
alternate setting such as in an SNF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
10, 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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 drug testing services provided to the enrollee on December 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 14, 
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 a modifier was not billed on the claim to represent the services as separate/distinct. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on November 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 30, 
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 a modifier was not billed on the claim to represent the services as separate/distinct. 
 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 71045 
is a column II code to column I code 32555. 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 imaging services provided to the enrollee on November 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on 
October 12, 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 a surgical assistant is not allowed for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 13160. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant 
services provided to the enrollee on October 12, 2021.