Persius/hicric huggingface dataset:
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 admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. She was medically stable without any 
acute exacerbations of chronic medical problems. Her physical function was at or near her baseline. As a 
practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care at 
the time of discharge from the hospital. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on December 21, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the level of service. The Plan denied your request. The Plan says rules for payment have not been met 
because the code at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (70450) 
provided on December 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 1, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered 
on January 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered 
on January 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva (denosumab). 
 
You asked the Plan to pre-approve Xgeva. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Xgeva. Our reviewer says that the 
requirements for coverage of Xgeva have not been met. Our physician reviewer found the Plan requires the 
enrollee to be supplementing with calcium and vitamin D and a trial of zoledronic acid before they will 
approve the requested drug. In this case, you have not tried and failed the required drugs. There is no 
documentation provided indicating that the required drugs would likely be less effective or have adverse effects 
for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (denosumab).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing rendered on November 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed 
adjacent to the CPT code for GeneSight testing. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX 
Z-Code. 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 pay for the GeneSight testing rendered on 
November 18, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on July 1, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not a covered 
service. 
 
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. The Plan argues that the requested testing is not covered when billed with codes 
0012M and 0013M, per Local Coverage Determination (LCD) L35396. However, the testing in this case was 
billed with code 81479. This is a covered code for the requested testing. The Plan has not provided 
documentation to substantiate its denial. Therefore, we decided that the Plan has to pay for the genetic testing 
provided on July 1, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for patient evaluation and management, first 30 to 74 minutes 
(99291) provided on May 28, 2021. 
 
You asked the Plan to pay for patient evaluation and management. You say that you have provided records to 
support the level of service. The Plan denied your request. The Plan says rules for payment have not been met 
because the available records do not support the service 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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the available documentation 
does not record the span of time over which services were provided. Based on this information, we decided that 
Medicare rules for coverage of patient evaluation and management have not been met. Therefore, we decided 
that the Plan does not have to pay for patient evaluation and management, first 30 to 74 minutes (99291) 
provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 4, 2021, to July 
22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the RAP claim was not 
submitted timely. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment within 5 calendar days after the start of care date for initial 30-day periods 
and within 5 calendar days after the from date for each subsequent 30-day period of care.  
 
We looked at the file and Medicare rules. In this case, a RAP claim was not submitted within 5 calendar days 
after the start of care date. 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 the home health 
services provided from July 4, 2021, to July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered 
on January 26, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the occupational therapy services (97535, 97110, 97166) provided from 
April 20, 2021, to May 7, 2021. 
 
You asked the Plan to pay for occupational therapy. You say that these services are supported as billed. The 
Plan denied your request. The Plan says that these services should be billed with code G0152, because they 
were provided in the home. 
 
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 97535, 97110 and 97166 are supported in the medical record. Specifically, the services 
at issue were not rendered or billed under a home health plan of care. Outpatient therapy services are payable 
under the Physician Fee Schedule when they are furnished by a provider to its outpatients in the patient's home. 
That means that these services were billed appropriately. Based on this information, we decided that Medicare 
rules for coverage of occupational therapy have been met. Therefore, we decided that the Plan has to pay for 
the occupational therapy services (97535, 97110, 97166) provided from April 20, 2021, to May 7, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TEmpus xF liquid panel rendered on September 24, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
TEmpus xF liquid panel rendered on September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs rendered on January 4, 2022. 
 
You asked the Plan to pay for these services. You say that you were unaware that the drugs were given to you. 
The Plan denied your request. The Plan says self-administered drugs are not covered. 
 
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 pay for the self-administered drugs 
rendered on January 4, 2022.  
 Benefits for these services 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the left knee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that six weeks of provider directed treatment have not been completed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found ordinarily a denial based 
on a lack of a six week trial of physical therapy would hold; however, you have Marfan's syndrome and two 
failed hip arthroplasty procedures. You have tried home exercise and non-steroidal anti-inflammatory drugs 
(NSAIDs) without relief. The Marfan's syndrome background gives cause for extra caution as these patients 
often have unstable joints in the first place and MRI of the affected knee would be prudent prior to any kind of 
therapy. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the left knee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance angiography (MRA) scan of the head 
(70544) provided on September 10, 2021. 
 You asked the Plan to pay for an MRA scan of the head. You say that you have provided medical records to 
support the level of service billed. The Plan denied your request. The Plan says rules for payment have not been 
met because the code at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 
is a column II code to column I code 70551. 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 a magnetic resonance angiography (MRA) scan of the head 
(70544) provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the complete upper denture (D5110) and lower partial denture (D5214). 
You say that waiting the standard time frame will jeopardize your health and ability to regain maximum 
function. The Plan denied your request. The Plan says these services exceed the maximum count allowed per 
period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one complete upper denture (D5110) and one lower partial denture (D5212, D5214, D5222 and D5226) every 
five plan years. The Plan paid for the complete upper denture and lower partial denture provided on March 9, 
2022, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the 
complete upper denture (D5110) and lower partial denture (D5214).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
inpatient skilled nursing facility care. 
 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 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee 
has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled 
nursing and/or skilled therapy services on a daily basis. Although further rehabilitation services would be 
appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex 
wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of 
chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower 
level of care. Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Zip Lumbar Fusion procedure. 
 
You asked the Plan to pre-approve the Aurora Zip Lumbar Fusion procedure. The Plan denied your request. 
The Plan says the Aurora Zip Lumbar Fusion procedure is not medically necessary and considered 
experimental and investigational. 
 
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 Aurora Zip Lumbar Fusion 
procedure. Our reviewer says that the Aurora Zip Lumbar Fusion procedure is not considered medically 
reasonable and necessary. Our physician reviewer found Aurora Zip Lumbar Fusion is experimental. More 
research is needed. 
 
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 Aurora Zip Lumbar Fusion procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Aurora Zip Lumbar Fusion procedure.