Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional therapy visits. 
 
You asked the Plan to pre-approve the additional visits. The Plan denied your request. The Plan says the 
additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says that additional skilled services are not necessary to restore or maintain function or to prevent deterioration of 
the enrollee's condition. Our physician reviewer found that the additional requested therapy generally is not 
accepted as specific and effective therapy for the enrollees condition beyond what was approved by the health 
plan. The enrollee has had prior therapy and the documentation does not reveal that the enrollee's functional 
level and deficits require the unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist beyond what was approved. The enrollee should be able to transition to an 
independent home exercise program with the already approved therapy. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. visits are not medically reasonable and necessary 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 the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 additional therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service March 4, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service March 4, 2022, billed 
with code 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 3, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on May 3, 2022.
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 is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 available clinical documentation does not show that the enrollee requires 
inpatient hospitalization during rehabilitation in an IRF 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve waterproof bed sheets (E1399). 
 
You asked the Plan to pre-approve waterproof bed sheets. You say that you disagree with the denial. You have 
incontinence issues and will ruin the mattress if you do not get the sheets. The Plan denied your request. The 
Plan says the requested waterproof bed sheets are not covered under Medicare. 
 
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 waterproof bed sheets (E1399).
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 is a medical necessity for you. The Plan 
denied your request. The Plan says rules for IRF care have not been met. 
 
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 are medically stable and do not need a physical medicine and rehabilitation 
physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At your current functional level, you do not need 3 hours a 
day for 5 days a week of therapies with multidisciplinary approach 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing for 22 or more drug classes 
(G0483) provided June 7, 2022. 
 You asked the Plan to pay for the drug testing. You say that you are requesting reconsideration and payment in 
full for the toxicology drug screen performed. The Plan denied your request. The Plan says under Medicare 
rules, the requested number of definitive urine drug classes are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the drug testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that definitive drug testing for 
22 or more drug classes (G0483) provided meets the medically necessary requirements listed in the LCD for 
Medicare coverage. The provided records do not document the results of a screening drug test that were 
positive, or the results of the screen were negative, and this negative finding was inconsistent with the patient's 
medical history. The records do not document this test was necessary due to the lack of a presumptive test (as 
may be the case for certain synthetic or semi-synthetic opioids). 
 
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 testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing for 22 or more drug classes (G0483) provided June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for direct therapeutic activities provided on August 12, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for direct therapeutic activities. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it 
was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for direct therapeutic activities provided on August 
12, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 22845) provided to the 
enrollee on May 18, 2022. 
 
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 records do not support the services billed. 
 
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 22845 is "Anterior instrumentation; 2 to 3 vertebral 
segments (List separately in addition to code for primary procedure)." 
 
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 the record indicates that the 
enrollee underwent L4-S1 discectomies and anterior arthrodesis. The National Correct Coding Initiative Policy 
Manual for Medicare Services instructs that the insertion of screws or flanges in Standalone Cage Systems is 
considered inclusive to the interbody biomechanical device and not separately reportable using the standalone CPT code 22845. 
 
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 (procedure code 22845) provided to the enrollee on May 18, 2022.
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 LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 appears to be improving and should only require short-term 
additional acute-care hospital services that can safely be provided 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 at 
the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from May 12, 
2022, to June 10, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for each admission to home health, the HHA 
notifies Medicare systems via submission of an NOA. For all beneficiaries receiving HH services in 2021 
whose services will continue in 2022, the HHA shall submit an NOA with a one-time, artificial 'admission' date 
corresponding to the "From" date of the first period of continuing care in 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the case record documents that the submitted 
NOA was filed with an incorrect date of admission and an incorrect Type of Bill code. Therefore, we decided 
that the Plan does not have to pay for home health services billed for dates of service from May 12, 2022, to 
June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional features for a prosthetic (L5781, L5910). 
 
You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your 
request. The Plan says the studies did not demonstrate that the use of a vacuum-assisted socket system (VASS) 
provided consistent statistical clinical significance. 
 
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 the features. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the literature reviewed indicates that further research is needed with clinical trials that recruit larger 
sample sizes and report long-term outcome data for the requested elevated vacuum suspension system (L5781). 
This request exceeds your needs. The request for L5910 also exceeds your medical need, as the documentation 
does not support any irreparable wear or damage to the prior alignable system or is unable to use the prior 
system that was approved in 2021. 
 
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 features have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional features for a prosthetic (L5781, L5910).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physical therapy evaluation and follow-up physical 
therapy treatment to be rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a physical 
therapy evaluation and follow-up physical therapy treatment to be rendered by the out-of-network (OON) 
provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on July 13, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $120 
copayment for emergency care.  
 
You have been asked to pay $120 copayment for emergency care. This item/service falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on July 
13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-fitted mandibular sleep apnea appliance 
(E0486). 
 
You asked the Plan to pre-approve the oral appliance. You say that please find the requested information to 
complete authorization below and the supporting material from the doctor attached. The Plan denied your 
request. The Plan says the records do not show that the enrollee meets all of the Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
We looked at the file, and Medicare rules. The records do not show that the enrollee has a diagnosis of 
obstructive sleep apnea and there are no documented sleep studies. Based on this information, we decided that 
Medicare rules for coverage of the oral appliance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a custom-fitted mandibular sleep apnea appliance (E0486).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that your primary care provider did the test. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and the Plan confirmed 
with the enrollee's primary care provider that they did not refer the enrollee to the OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 22, 
2022, by an out-of-network (OON) provider.