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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to walk without your walker and 
have lost your mobility. You state you are needing to learn how to walk with your walker all over again to be 
able to complete your daily activities. The Plan denied your request. The Plan says the stay is not medically 
necessary based on SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 would like IRF services to be covered. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested IRF services 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 you are medically stable and do not need physical medicine and rehabilitation 
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 rehabilitation nursing needs are 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. You need routine physical 
therapy and occupational therapy and that can be safely provided in a skilled nursing facility. An IRF 
admission is not medically necessary based on medical stability and lack of medical complexity, and lack of 
rehab nursing needs. The documentation does not support the necessity for admission to an IRF. While you 
may benefit from physical therapy and occupational therapy, your rehabilitation can be safely provided at a 
lower intensity and alternate setting such as in a skilled nursing facility. 
 
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 pharmacogenomic testing provided on June 3, 2021. 
 
You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this claim has not been billed correctly. 
 
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 pharmacogenomic testing provided on 
June 3, 2021. have been met. Specifically, the documentation submitted does not include sufficient clincial 
information to verify why this testing was ordered, if it was medically necessary or how the results will affect 
the enrollee's treatment. The documentation does not show that the requested pharmacogenomic testing was 
ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for 
therapeutic decision-making regarding the need for the use of any specific drug. Therefore, we decided that the 
Plan does not have to pay for pharmacogenomic testing provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 You asked the Plan to pre-approve the requested testing. You say that there is extensive cancer in your family. 
The Plan denied your request. The Plan says the testing is considered a screening. 
 
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. The file does not show that you have a personal history of breast, 
ovarian, fallopian tube, primary peritoneal, or pancreatic cancer. The requested testing without a personal 
history is considered a screening. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear stress test. 
 
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 nuclear stress testing is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
hypertension. The enrollees pre-test probability for an abnormal test is low and there is no documentation that 
his ECG shows an uninterpretable pattern. There is no evidence provided that would support the need for 
radionuclide stress testing. In summary, there is insufficient documentation to support the medical necessity for 
the requested cardiac stress testing in this enrollees clinical management. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a nuclear stress test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oxygen concentrator, single delivery port, capable of 
delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT code E1390) and 
oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the 
prescribed flow rate (CPT code E1391). 
 You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the records to do show that the enrollee meets Medicare criteria set forth in the LCD. 
The Plan states the enrollee's oxygen percentage must be at or below 88% and the enrollee's oxygen percentage 
was above 88%. 
 
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 DME. Our physician reviewer 
found home oxygen is not medically necessary. This enrollee has respiratory symptoms and had COVID-19 
illness in January. Vital signs in the medical record show SpO2 consistently above 95% breathing room air. 
Medical documentation does not mention any need for oxygen. The denial is upheld. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen 
concentration at the prescribed flow rate (CPT code E1390) and oxygen concentrator, dual delivery port, 
capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT code E1391).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says having this procedure for pain in this location is not 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 service. Our physician reviewer 
found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the 
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. 
Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. The review has 
determined that the requested procedures in this case are 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, 
fluoroscopy or computed tomography) (CPT code 64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on December 10, 
2021. 
 
You asked the Plan to pay for the provided device. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 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 does not indicate that the enrollee has had an in-
person visit with their treating physician, within six months of the device being provided, to assesses adherence 
to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules 
for coverage of the provided device have not been met. Therefore, we decided that the Plan does not have to 
pay for the continuous glucose monitor provided on December 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy services (97036) and manual therapy 
techniques (97140) provided from November 12, 2020, to December 9, 2020. You asked the Plan to pay for therapy services. You say that these services were medically necessary and were 
billed appropriately. The Plan denied your request. The Plan says these services are missing a necessary 
modifier for always-therapy services, and therefore were not billed according to Medicare guidelines. 
 
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 codes 97036 and 97140 are 
both indicated as always therapy services. Medicare rules say that always therapy services must be 
delivered by a provider who is recognized as qualified by Medicare to perform the services, and claims for 
these services must include the appropriate modifier to distinguish the discipline of the plan of care under 
which the service is delivered. 
 
We find that CPT codes 97036 and 97140 not supported in the medical record. Specifically, these services are 
classified as always therapy services by Medicare but were not billed with an appropriate modifier. Based on 
this information, we decided that Medicare rules for coverage of therapy services have not been met. Therefore, 
we decided that the Plan does not have to pay for infrared therapy services (97036) and manual therapy 
techniques (97140) provided from November 12, 2020, to December 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Muscle, myocutaneous, or fasciocutaneous flap; head and 
neck with named vascular pedicle (15733) provided on December 6, 2021. 
 
You asked the Plan to pay for code 15733. You say that the medical records support the billing of code 15733 
provided on December 6, 2021. The Plan denied your request. The Plan says the medical records do not 
support the billing of code 15733 provided on December 6, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15733 is 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 code 15733. Our reviewer says that the medical records do not support the billing of code 15733 provided on December 6, 2021. Our reviewer found the record indicates 
that the enrollee underwent a procedure. The operative note does not describe the creation of a flap based upon 
a named vascular pedicle but rather the elevation of tissue. The elements of the coverage criteria are not 
satisfied.  The requested service is not recommended. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 15733 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle 
(15733) provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says you do not use insulin with at least three daily injections. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this request is not covered. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. This patient has severe COPD, but there is 
no documentation of CO2 retention on an arterial blood gas done as an outpatient while the patient is stable. 
Thus Medicare criteria for a ventilatory assist device are not met. In addition, Medicare does not cover a home 
ventilator when used as BiPAP. There is no evidence that BiPAP was tried and failed at home. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator.  
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the glucose test strips (A4253). 
 
You asked the Plan to pre-approve the glucose test strips. You say that the items are medically necessary The 
Plan denied your request. The Plan says a review of your claims was performed and a recent paid claim was 
found for 100 test strips on January 13, 2022. The recent attempted fill is rejecting because it will result in 
a quantity greater than allowed in a 90 day time frame. 
 
The Plan must follow Medicare rules. Medicare rules say that the quantity of test strips (code A4253) and 
lancets (code A4259) that are covered depends on the usual medical needs of the beneficiary and whether or 
not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having Type 1 or 
Type 2 diabetes mellitus. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the glucose test strips have not been met. Therefore, we decided that the Plan does not have to pre-
approve the glucose test strips (A4253).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on 
October 12, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the requested item was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for pneumatic 
compression devices have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for prevention of venous thromboembolism, regardless of how they are billed on the 
claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) 
provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by 
Medicare for the prevention of deep vein thrombosis before and/or during surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675, E0673).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between the billed CPT codes 
and 81445. 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 codes 
81194, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81309, 81317 and 81401 are column 
II codes to column I code 81445. This claim has not been billed with an appropriate modifier to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on February 19, 2021.