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

 
We decided that the Plan does not have to pre-approve a LINX Reflux Management System. 
 You asked the Plan to pre-approve a LINX Reflux Management System. 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 coverage for the TIF (Transoral Incisionless 
Fundoplication) procedure is for treatment of patients in whom proton pump inhibitor therapy fails. 
 
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 LINX Reflux Management System. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the available 
documentation does not support that you have symptomatic chronic gastroesophageal reflux with greater than 6 
months of symptoms which is not completely responsive to Proton Pump Inhibitors as judged by 
gastroesophageal reflux disease (GERD) health-related quality of life (HRQL) scores of < or equal to 12 while 
on proton pump inhibitors (PPIs) and > or equal to 20 when off for 14 days (or a difference of > or equal to 10 
of the scores between off and on 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 a LINX Reflux Management System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a LINX Reflux Management System.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for electrical stimulator leads (A4595) provided on June 8, 2022. 
 
You asked the Plan to pay for electrical stimulator leads. You say that this was billed correctly. The Plan 
denied your request. The Plan says that there is not a valid proof of delivery for this item. 
 
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 states that a valid proof of delivery was not provided because the proof 
of delivery was not itemized. However, there is an itemized delivery ticket in the submitted documentation 
with the carriers tracking number along with the proof of delivery. The Plan has not provided a reason this is 
invalid.  Therefore, we decided that the Plan has to pay for electrical stimulator leads (A4595) provided on 
June 8, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 21, 2022 to 
July 19, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 21, 2022 to July 19, 
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 medically necessary. The Plan denied 
your request. The Plan says the records do not show that the enrollee needs an intensive team for care. The Plan 
says that the services needed 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for dehydration, acute kidney injury and urinary tract infection. The enrollee's medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2083 billed for date of service June 8, 
2022. 
 
You asked the Plan to pay for procedure code G2083. You say that you would like the Plan to reconsider their 
denial of payment. 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 G2083 is 1. The MAI value for this code is 2. You billed 84 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G2083 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G2083 billed for date of service June 8, 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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be more stable and 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. There are not services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) colonography. 
 
You asked the Plan to pre-approve the CT colonography. You say that you do not want to have an invasive 
colonoscopy and feel that this imaging is preferable. The Plan denied your request. The Plan says you do not 
meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that CT colonography may be covered when the criteria 
listed in the Medicare rules section 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 the CT colonography. Our reviewer 
says that the requested imaging is not medically reasonable and necessary. Our physician reviewer found the 
enrollee has a family history of colon cancer and had a chief complaint of weight loss. It is documented that the 
enrollee is reluctant to undergo an invasive colonoscopy. The enrollee has not had a prior colonoscopy. The 
enrollee does not have one of the covered conditions for this imaging.  
  
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 CT colonography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) colonography.
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 the inpatient rehabilitation facility (IRF) services you 
are requesting do not meet the requirements for approval. The Plan denied your request. The Plan says the 
services requested are 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 1, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 1, 2022.
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 enrollee would benefit from skilled nursing 
services due to their medical complexity. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for skilled nursing facility (SNF) 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on August 2, 2022. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says per 
Medicare regulations, Licensed Mental Health Counselors are not eligible to bill Medicare for mental health 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy services provided on August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is approved for treatment of prostate 
cancer. The Plan denied your request. The Plan says this is not the standard of care for prostate cancer. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while proton therapy is an accepted treatment approach, any potential benefit or 
detriment of proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational 
question. Other treatment approaches are also highly effective and well tolerated. Thus, whether proton therapy 
affords a benefit over other standard approaches for prostate cancer is an area of investigation and remains 
controversial. Proton therapy would exceed the enrollee's medical needs and would not be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that the place of service code is correct. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services (66984) provided on June 3, 2021. 
 
You asked the Plan to pay for the ophthalmology services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ophthalmology services was not filed until July 25, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ophthalmology services (66984) provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0650, E0651) provided to 
the enrollee from January 13, 2022, to January 16, 2022. 
 
You asked the Plan to pay for the device. You say that this was medically necessary. The Plan denied your 
request. The Plan says the diagnosis code of lymphedema was listed on the claim but was not documented 
within the medical records. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record offers no evidence of lymphedema and there is no evidence of an indication for a 
pneumatic compression pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pay for a pneumatic compression device (E0650, E0651) provided to the enrollee from January 13, 2022, to 
January 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 and 77065 billed for date of service 
August 17, 2022. 
 
You asked the Plan to pay for procedure code 76642 and 77065. You say that the records support separate 
services rendered. 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 76642 and 77065 is 1. The MAI value for each of the codes is 2. You 
billed 2 units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code 76642 and 77065 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76642 and 77065 billed for date of service August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 home tests purchased on 
August 13, 2022. 
 
You asked the Plan to pay for OTC COVID-19 home tests. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and OTC 
COVID-19 tests is an OTC item. The Plan does not provide reimbursement for OTC items purchased in a store, 
and although Medicare provided coverage of COVID-19 tests on the date in question, the participating provider 
needed to bill Medicare directly for this service. The Medicare Advantage Plan is not responsible for coverage of this test. Therefore, we decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 
home tests purchased on August 13, 2022.