Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF is not medically 
necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the documentation shows that the enrollee has complex functional impairments with multiple fractures of 
weight bearing joints. Evaluating therapists recommend intense therapy setting and that enrollee would tolerate 
3 hours of therapy per day. Clinical documentation shows that the enrollee has multiple active comorbidities 
thus would be expected to require continued inpatient hospitalization during rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided June 14, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the prescribing physician 
recommends an extended, lifetime use of equipment as they are diagnosed with chronic pain and compromised 
mobility without the option for surgical correction. The Plan denied your request. The Plan says none of the 
diagnosis codes on the claim line meet medical necessity for procedure code A4595. 
 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 claim was billed with diagnosis codes M79.18 - Myalgia, other 
site and M54.16 - Radiculopathy, lumbar region. This device including supplies is not a Medicare covered 
benefit for Myalgia and radiculopathy. Based on this information, we decided that Medicare rules for coverage 
of Electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) (A4595) provided June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635, 64636). 
 
You asked the Plan to pre-approve RFA. You say that your back is not feeling well. You say that you got your 
shot and felt better. You also say that you are in pain and need another one. The Plan denied your request. The 
Plan says the injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) 
radiofrequency (RFA) sessions will be reimbursed per rolling 12 months. 
 
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 RFA. Our reviewer says that the 
requested RFA are not medically necessary. Our physician reviewer found the requested RFA exceeds the 
utilization criteria of 2 radiofrequency (RFA) sessions per rolling 12 months. Therefore, the requested RFA are 
not 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 RFA have not been met.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635, 
64636).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit (90832) provided on July 11, 2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support that the enrollee has the 
cognitive ability to interact with the therapist adequately for successful treatment and improved function. 
 
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 psychotherapy service. Our reviewer 
says that the psychotherapy service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate the enrollee was exhibiting any 
symptoms of her illness which would require them to be seen for individual psychotherapy. Therefore, the 
reviewer found that the psychotherapy performed was 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 the psychotherapy service have not been met. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy visit (90832) provided on July 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the supporting information 
demonstrates the enrollee clearly meets FDA indications for use. The Plan denied your request. The Plan says 
the Intracept procedure is considered experimental and/or unproven as there is not enough medical proof that 
shows the safety and efficacy of this treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the thermal destruction of intraosseous basivertebral nerve (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G0402 and G0463 provided on July 8, 2022. 
 
You asked the Plan to pay for codes G0402 and G0463. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes G0402 and G0463 are not supported in the medical record. Specifically, In the 
Integrated Outpatient Code Editor (IOCE) HCPCS/CPT codes G0463-25 and G0402 are assigned Ambulatory 
Payment Classification (APC) groups 5012 respectively. Both APC groups have a status indicator V for a 
Clinic or emergency department visit. Two emergency department visits were billed on the same day and the 
non-participating facility billed the second emergency department visit claim without condition code G0 
indicating that multiple medical visits occurred on the same day in the same revenue center but the visits were 
distinct and constituted independent visits. Therefore, these codes are not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of codes G0402 and G0463 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes G0402 and G0463 provided on July 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zarxio and an antiemetic regimen 
comprising fosaprepitant, ondansetron and dexamethasone. 
 
You asked the Plan to pre-approve Zarxio, fosaprepitant, ondansetron and dexamethasone. You say that the 
requested drugs are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested drugs have been prescribed for off-label and not medically accepted uses. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Zarxio, fosaprepitant, ondansetron and 
dexamethasone. Our reviewer says that the requested drugs are not medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee's treatment regimen of gemcitabine and paclitaxel is 
considered to have less than a 10% incidence of febrile neutropenia and to be of low emetogenic potential. The 
FDA has not stated that the requested drugs are indicated for the enrollee's condition. The Medicare-approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drugs in the enrollee's clinical situation. No literature from Medicare-approved cancer journals was submitted for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zarxio, fosaprepitant, ondansetron and dexamethasone have not been met. 
Therefore, we decided that the Plan does not have to pre-approve treatment with Zarxio and an antiemetic 
regimen comprising fosaprepitant, ondansetron and dexamethasone.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 2, 2021 to 
March 7, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
service was medically necessary. The Plan denied your request. The Plan says DRG 872 more appropriately 
describes the services at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that DRG 871 is not supported. Our physician reviewer found the medical records do not support DRG 871 as 
originally billed.  DRG 872 is more appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 2, 2021 to March 7, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 14, 2022, billed with 
codes 81225, 81226, 81227, 81401, 81231, 81240, 81241, 81291, 81328, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was billed with covered CPT 
codes. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the 
claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 14, 2022, billed with codes 81225, 81226, 81227, 81401, 81231, 81240, 81241, 81291, 81328, and 
81335.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on July 
23, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that there is no documentation that a 
psychiatric disorder currently exists, and there is lack of documentation of active symptoms either through 
observation or testing. The Plan denied your request. The Plan says there is no documentation that a psychiatric 
disorder currently exists, and there is lack of documentation of active symptoms either through observation or 
testing. 
 
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 nursing facility care. Our reviewer says 
that the requested nursing facility care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that a psychiatric disorder existed on the date of service in 
this case. The reviewer found there was lack of documentation of active symptoms either through observation 
or testing. Therefore, the reviewer found that the services at issue in this case were not medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the nursing facility care have not been met. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care (99309) provided on July 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical orthosis (L0180) provided on July 7, 2022. 
 
You asked the Plan to pay for the cervical orthosis. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation submitted did not 
sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records do not indicate that the ordered equipment was discussed with the 
enrollee by the ordering physician. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
cervical orthosis (L0180) provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for lymphedema. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy for lymphedema. You say that bioimpedance 
spectroscopy for lymphedema is medically necessary. The Plan denied your request. The Plan says 
bioimpedance spectroscopy for lymphedema is unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bioimpedance spectroscopy for 
lymphedema. Our reviewer says that the requested bioimpedance spectroscopy for lymphedema is not 
considered medically reasonable and necessary. Our physician reviewer found bioelectrical impedance analysis 
for body composition is considered investigative and unproven. There is insufficient reliable evidence in the 
form of high-quality peer-reviewed medical literature to establish the efficacy or effects on health care 
outcomes. The review has determined that the requested bioimpedance spectroscopy for lymphedema in this 
case is not medically reasonable or necessary. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy for lymphedema have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bioimpedance spectroscopy for lymphedema.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the records support the billed services. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on January 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the wound care services provided on January 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are 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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope, or any other apparent indication for an ILR. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in your 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 placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).