Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the Intracept procedure is considered experimental/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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the proprietary laboratory analyses (PLA) codes (0242U) 
provided May 26, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you believe that there has been a 
misinterpretation of the CMS guidelines and you have billed the place of service and the date of service for the 
claim accurately. The Plan denied your request. The Plan says the records do not support the service billed. 
 
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. The submitted records indicates that the specimen was obtained in an 
on-campus outpatient hospital POS 22. The enrollee resides in Illinois and billing laboratory is located in 
California. Based on this information, we decided that Medicare rules for coverage of the laboratory service 
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 proprietary laboratory analyses (PLA) codes (0242U) provided May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 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 claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an ooutpatient hospital setting 
and should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 11, 
2021, to August 4, 2021. 
 
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the SNF benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 The file shows that the enrollee received 100 days of SNF care during the benefit period from January 26, 
2021, to July 10, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 11, 2021, to 
August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that Prolia is not being prescribed for a medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. Prolia is not FDA-approved for the enrollees diagnosis. The use of 
Prolia is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of Prolia. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no actual records present from a treating physician or therapist that 
documented why this device is appropriate and recommended. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the current clinical guidelines do not indicate the powered upper extremity range of motion assist device 
to be of proven benefit in amyotrophic lateral sclerosis. Although records from the device vendor argue 
medical necessity of the requested device, no records from the enrollees actual treating provider clarify why 
the requested device is the most appropriate treatment for the enrollees condition. The provided records also 
report the enrollee has a shoulder subluxation which may be a contraindication to use of the requested device. 
 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 pre-approve a powered upper extremity range of motion assist device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 3, 2021 by an out-of-
network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on September 3, 2021 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 July 27, 2021.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the definitive drug testing (G0480). We decided that the Plan does not 
have to pay for presumptive drug testing (80307) and mass spectrometry (83789).  
 
You asked the Plan to pay for the definitive drug testing (G0480). You say that you would like reconsideration 
based on the records submitted. The Plan says that the record does not include a signed physician order. 
 
We decided that the Plan has to pay for the definitive drug testing (G0480).  
 
The Plan follows Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, 
and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have been met. Specifically, the signed physician order clearly requests the 
testing of these drug classes. In this case, the Plan's denial is not substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the definitive drug testing (G0480).  
 
We also decided that the Plan does not have to pay for presumptive drug testing (80307) and mass 
spectrometry (83789). 
 
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for 
any item or service, the information submitted by the supplier or provider must corroborate the documentation 
in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. The 
rules also say that providers must report services correctly. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, the physician order does not include a request 
for a presumptive drug test nor do the records support that a presumptive drug test was rendered. Additionally, 
CPT code 83789 is a column II code to both CPT codes G0408 and 80307. CPT code 83789 is not separately 
reimbursable. Therefore, we decided that the Plan does not have to pay for presumptive drug testing (80307) 
and mass spectrometry (83789). 
 
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 lab services provided on September 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that these lab services were billed correctly. The Plan 
denied your request. The Plan says you billed an incorrect place of service on the claim. 
 
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 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 September 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700-26 billed for date of service October 
28, 2021. 
 You asked the Plan to pay for procedure code 76700-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment 
for 93976. 
 
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 
76700-26 is a column II code to column I code 93976. 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 procedure code 76700-26 billed for date of service 
October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve the Keytruda. You say that Keytruda is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 the Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic 
squamous non-small cell lung cancer. The record does not include the result of tumor genetic testing. The 
record indicates the enrollee has poor performance status. The Food and Drug Administration has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No 
literature from Medicare approved cancer journals were 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 the Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 98943 and 99202 provided by a chiropractor 
on October 21, 2021. 
 
You asked the Plan to pay for procedure codes 98943 and 99202. You say that you were suffering for several 
days with neck, back, and shoulder pain.  You said that you used a network chiropractor, so you don't 
understand why these services were not covered. The Plan denied your request. The Plan says these services 
are not covered under your contract. The Plan did pay for the manual manipulation of the spine (code 98941) 
you received. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Specifically, code 98943 
represents chiropractic manipulation of any area other than the spine, and code 99202 represents a new patient 
office visit.  Neither of these services is covered by your contract. Therefore, we decided that the Plan does not 
have to pay for procedure codes 98943 and 99202 provided by a chiropractor on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance services provided on June 9, 2021. 
 
You asked the Plan to pay for the services provided. You say that the service was billed appropriately. The Plan 
denied your request. The Plan says the service was not billed as required.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 77002 is fluoroscopic guidance for needle placement 
(e.g., biopsy, aspiration, injection, localization device) (List separately in addition to code for primary 
procedure).  
 
We find that CPT code 77002 is not supported in the medical record. Specifically, the file does not show that 
the service at issue was billed with an appropriate primary procedure. 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 fluoroscopic guidance services provided on June 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no benefit for additional transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pennsaid solution 2%. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage for this drug may be provided through a Medicare Part D benefit. 
 
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 Pennsaid solution 2%.