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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare guidelines 
for LTACH admission and waiting will limit the enrollee's ability to regain function. The Plan denied your 
request. The Plan says the documentation does not show that the enrollee needs continued treatments and care 
that can only be given in a hospital setting. When the enrollee is ready to leave the hospital they can receive 
care in another setting like an inpatient rehabilitation facility, skilled nursing facility, or home health services. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be completed at the current facility until a 
lower level of care is appropriate. The patient does not require services at the LTACH that are not already 
available at the current facility. 
 There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to 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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 3, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the medical records do not 
contain documentation of definitive laboratory results for 22 or more drug classes, including metabolites to 
support the coding criteria for G0483. Based on this information, we decided that Medicare rules for coverage 
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing coded G0483 provided on March 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical condition supports 
the discharge plan to LTACH. The Plan denied your request. The Plan says the documentation show that the 
enrollee is medically stable and once the enrollee is ready to leave the hospital, they can receive services in 
another setting like a skilled nursing facility or at home with health services. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be completed at the current facility until a 
lower level of care is appropriate. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been bedridden for a month and are losing 
mobility due to not being able to walk with a therapist. The Plan denied your request. The Plan says you do not 
meet the requirements for approval. 
 
  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 you are medically stable and no acute rehab nursing needs were identified or 
documented. While the enrollee may benefit from continued physical and occupational therapy, your rehab 
needs can be safely provided in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve Repatha. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Repatha is not covered under the enrollee's Medicare Part B 
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 Repatha.  
 
Benefits for Repatha 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure consequent to chronic obstructive pulmonary disease. The case file does not contain documentation that 
BiPAP with backup rate and AVAPS has been utilized and failed. A home mechanical ventilator set in VAPS 
mode with Auto-EPAP could be delivered by BiPAP. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on November 8, 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 surgical services provided on November 8, 
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Feraheme 510mg/17ml solution medication 
(Q0138). 
 
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that there is no documentation of intolerance, trial with 
failure, or contraindications to the preferred medications: Ferrlecit, Sodium ferric-gluconate, Infed or Venofer.  
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 this medication. Our reviewer says that 
the enrollee does not meet criteria for coverage of this medication. Our physician reviewer found that the 
enrollee has previously been treated with the medication Venofer but there is no indication that the enrollee has 
tried and failed the other required drugs (Ferrlecit, Infed or Sodium Ferric Gluconate). Additionally, based on 
the medical records provided and the Medicare-approved major drug compendia, there is no indication that the 
Ferrlecit, Infed or Sodium Ferric Gluconate medications would likely be less effective and/or likely have 
adverse effects for the enrollee. A search of the Food and Drug Administration Drug Shortage database does 
not indicate a shortage for the medication Infed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Feraheme 510mg/17ml solution medication (Q0138).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (A0425) provided on December 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has 
been exceeded. 
 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 A0425 is 250. You billed 271 units of this code, exceeding the MUE. 
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 services (A0425) provided on December 29, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at a skilled nursing facility (SNF). 
 You asked the Plan to pre-approve a continued stay. You say that your provider advised additional days at the 
SNF would be beneficial. The Plan denied your request. The Plan says the requested SNF continued stay is not 
medically necessary. 
 
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 a continued stay. Our reviewer says that 
the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found that 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 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 a continued stay have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continued stay at a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty wheelchair (K0006). 
 
You asked the Plan to pre-approve a wheelchair. You say that the heavy-duty wheelchair is medically 
necessary and you are appealing the denial. The Plan denied your request. The Plan says the available medical 
records do not support necessity of the device as defined by Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clear documentation that this enrollee has a personal mobility deficit that impairs 
participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in 
customary locations within the home, that the patient's mobility deficit cannot be helped by the use of a walker 
or cane, that the enrollee can safely operate a heavy-duty wheelchair. The records report the enrollee weighs 
265 pounds and no severe spasticity is documented.  
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty wheelchair (K0006).
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 there is no indication zoledronic acid would likely be less effective, and/or cause 
adverse effects for the member. 
 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. The Plan requires a a history of an osteoporotic fracture or that the 
enrollee has tried, or cannot use, zoledronic acid before approving the requested drug. In this case, the patient 
has not tried and failed the required drug. There is no documentation provided indicating that the Plan's 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician 
reviewer found that the enrollee's condition does not meet step therapy criteria for 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to appeal 
the denial of the authorization. The Plan denied your request. The Plan says the services requested are not 
medically necessary. 
 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the patient's notes 
from her hospital admission are not enclosed in the materials submitted for this review.  She saw her PCP in 
July at which time a normal physical exam was noted.  The notes state the patient refused to discuss her 
symptoms requiring the MRI scan and left the office without explanation.  The notes do not reveal a red flag on 
physical exam and the ED records were not enclosed.  Absent this information the medical necessity of the 
patient requested MRI cannot be established based upon the information provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation of malignant prostate tissue, transrectal, with 
high intensity-focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve HIFU. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that HIFU is only covered for certain indications. 
 
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 HIFU. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has a palpable prostate nodule and PSA of 2.4 ng/mL that was evaluated 
with ultrasound guided needle biopsy. Pathology revealed stage T1c, Gleason's grade 4+3 adenocarcinoma. 
The request is for primary treatment rather than recurrent prostate cancer as described in the LCD. The enrollee 
does not meet all of the LCD criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment of pelvic ring fracture (27216) provided on 
February 13, 2022. 
 
You asked the Plan to pay for treatment of pelvic ring fracture. You say that you have provided medical 
records to support the services billed. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 code 27216 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 27216 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of treatment of pelvic ring fracture have not been met. Therefore, we decided that the Plan does not 
have to pay for treatment of pelvic ring fracture (27216) provided on February 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 2, 2021. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0483. 
 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 83789 
is a column II code to column I code G0483. 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 83789 billed for date of service June 2, 2021.