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

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD) services. 
 
You asked the Plan to pre-approve PILD services. You say that this procedure is medically necessary for the 
enrollee's condition. 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 PILD services will be covered by Medicare when 
provided in a clinical study. 
 
We looked at the file and Medicare rules. In this case, there is no evidence provided that the enrollee is 
currently a participant in a clinical trial. Based on this information, we decided that Medicare rules for coverage 
of PILD services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous image-guided lumbar decompression (PILD) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing provided on March 18, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that urine PCR amplification techniques raise considerable concerns regarding contamination from one 
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results 
may also be challenging.  Amplification of organisms representing latent infection or colonization cannot be 
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine PCR testing provided on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder genetic testing services provided on March 4, 
2022. 
 
 
 
 
 
 
 
 
 
 
 
 
 You asked the Plan to pay for the CxBladder genetic testing services. You say that you would like this claim 
reprocessed and approved for payment based on medical necessity. The Plan denied your request. The Plan 
says this testing is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy in place for 
CxBladder genetic testing services. Based on this information, we decided that Medicare rules for coverage of 
the CxBladder genetic testing services have not been met. Therefore, we decided that the Plan does not have to 
pay for the CxBladder genetic testing services provided on March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service December 
14, 2021. 
 
You asked the Plan to pay for procedure code 36000. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says procedure code 36000 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 23, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that the provider sold his practice, so you tried 
submitting this claim yourself. The Plan denied your request. The Plan says the claim for these chiropractic 
services was not submitted with the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires the AT modifier on 
chiropractic claims. The provider of the services in dispute in this case did not bill the AT modifier as required, 
so the claim cannot be processed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to 
pay for chiropractic services provided on August 23, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided to the enrollee from January 4, 2022, to 
January 18, 2022. 
 
You asked the Plan to pay for the services. You say that the plan has not given guidance on how to submit the 
Notice of Admission. The Plan denied your request. The Plan says that a corrected claim is needed with a valid 
Notice of Admission (NOA). 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It is not completely clear what the plan is basing their denial on in this case. The 
plan seems to take issue with the NOA having a date of service of January 1, 2022, with the admission date for 
home health being in 2021, on December 21, 2021. Because of this, the NOA is apparently invalid. However, it 
appears there was a period of care from December 21, 2021 to December 31, 2021, with a second non-
continuous period of care from January 4, 2022 to January 18, 2022. A NOA for this period submitted on 
January 1, 2022 would be appropriate. Therefore, we decided that the Plan has to pay for home health services 
provided to the enrollee from January 4, 2022, to January 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 the enrollee is cleared for discharge, and they need 
the next level of care. The Plan denied your request. The Plan says the criteria for admission to a SNF was not 
met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia provided on April 1, 2022. 
 
You asked the Plan to pay for the anesthesia. The Plan denied your request. The Plan says the anesthesia was 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the use of Moderate or Deep Sedation, General 
Anesthesia, or Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these 
procedures and therefore, is not considered medically reasonable and necessary. Even in patients with a needle 
phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must 
clearly establish the need for such sedation in the specific patient. 
 
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 anesthesia. Our reviewer says that the 
requested anesthesia was not medically reasonable and necessary in this case. Our physician reviewer found 
that there was no indication for a separate anesthesia provider for this procedure. The sedation was 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 anesthesia have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia provided on April 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 12, 
2022 to May 15, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was authorized. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 12, 2022 to May 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for ambulance services. You say that the services provided were medically 
necessary. 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 ambulance services provided on May 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 1, 2021, 
to November 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that the type of bill is valid for home care claims. 
The Plan denied your request. The Plan says the claim was billed with an invalid type of bill. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim was billed with a type of bill 324. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from November 1, 2021, to November 
26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are a fall risk, and it would be unsafe to allow 
you to return to an independent living level without a lower level of care to regain your strength. You were 
independent prior to blockage. The Plan denied your request. The Plan says this is not medically necessary, the 
services you need can be provided safely 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 your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTAC 
admission criteria under CMS guidelines. 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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam by a pathologist (88305) and special stain 
(88312) provided on June 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained from the enrollee's primary care 
physician. 
 
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 provider in this case is not a network provider with the Plan. 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 tissue exam by a pathologist (88305) and special stain 
(88312) provided on June 16, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says medical records indicate that enrollees needs are being 
met at the current facility. 
 
 
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 transfer to the LTACH is not medically necessary as the enrollee is not yet stable for 
transfer and as it would not be clinically advantageous at this time. Completion of treatment at the current 
facility is recommended. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water-circulating heat pad with pump (code E0217) 
provided from October 4, 2021, to October 25, 2021. 
 
You asked the Plan to pay for the water-circulating heat pad with pump. You say that medical literature shows 
the efficacy of this item. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that water-circulating heat pads with pumps are not 
covered. Therefore, we decided that the Plan does not have to pay for the water-circulating heat pad with pump 
(code E0217) provided from October 4, 2021, to October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol Hcl for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has found relief with this drug. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tramadol Hcl for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pegloticase. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document physical 
examination or radiologic evidence of tophi for the enrollee. The records do not document the frequency of 
prior gout flares or the duration or dose of allopurinol previously used to clarify failure of this therapy. The use 
of Pegloticase is not supported by the Medicare-approved drug compendia. The services are not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Pegloticase.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan for the enrollee. 
 
You asked the Plan to pre-approve a CT scan. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that there does not appear to be a current complaint or clinical problem. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that a CT 
scan is medically reasonable and necessary. The operating neurosurgeon specified in his note that a 1 year post 
op CT of the cervical spine is necessary in order to evaluate solid bone incorporation of the multilevel anterior 
interbody fusion material. Since multiple levels have been fused the request is reasonable. Our physician 
reviewer found that the enrollee's condition meets criteria for coverage of a CT scan. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.