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 enrollee will clearly benefit from acute 
rehabilitation to optimize the level of functioning prior to returning home. The Plan denied your request. The 
Plan says the enrollee does not have complex medical or intensive rehabilitation needs requiring supervision by 
a rehabilitation physician and an intensive and coordinated interdisciplinary team in a resource intensive 
inpatient hospital environment. 
 
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 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 an esophagogastroduodenoscopy (EGD), with delivery 
of thermal energy via Stretta therapy (43257). 
 
You asked the Plan to pre-approve the Stretta procedure. You say that the Stretta procedure is noninvasive is 
considered an alternative to fundoplication surgery and is not associated with any significant morbidity or 
safety issues. The Plan denied your request. The Plan says the benefit of the Stretta Procedure is not considered 
reasonable and necessary for the diagnosis or treatment of an injury or disease. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Stretta procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve an esophagogastroduodenoscopy (EGD), with delivery of thermal energy via Stretta therapy (43257).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0480, 80307) provided on October 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (G0480, 80307) provided on October 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a continuous glucose monitor (CGM) on February 10, 2022. 
 
You asked the Plan to provide a continuous glucose monitor (CGM). You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the criteria for approval has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a continuous glucose monitor (CGM) have not 
been met. Therefore, we decided that the Plan does not have to provide a continuous glucose monitor (CGM) 
on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 6, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on June 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 20, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service October 20, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on April 13, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee is bed confined, and is transferred to from stretcher with two man lift by draw sheet and unable to 
assist. You also say the enrollee is a high fall risk with multiple occurrences, and requires oxygen during 
transport. The Plan denied your request. The Plan says this claim does not meet the requirements for coverage. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation by ambulance to the enrollees 
dialysis appointment was not medically necessary. Our physician reviewer found the enrollee did not require 
the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Our reviewer also found that transportation could have been provided by other means (i.e., stretcher 
van) without endangering the enrollees condition.  
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation (99397) provided on June 14, 2022. 
 You asked the Plan to pay for the evaluation and management service. You say that this service was performed 
by your in-network primary care provider. You also say that this should be covered. The Plan denied your 
request. The Plan says the billed code is not covered by Medicare. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the evaluation and management service have not been met. Specifically, procedure code 99397 is 
not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic 
comprehensive preventive medicine reevaluation (99397) provided on June 14, 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 your husband is bedridden and has lost 
the strength and mobility that a long term acute hospital will assist in the therapy needed. The Plan denied your 
request. The Plan says the records do not show the enrollee has a condition that meets the criteria for LTACH 
care. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH and the enrollee is receiving appropriate care at the present acute care 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 24, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services provided on September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular cytogenetics; DNA probe, each (e.g., FISH) 
(88271). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested testing is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee has a diagnosis of disorder of white 
blood cells, unspecified and thrombocytosis, unspecified. Neither of these diagnosis codes are listed in the 
LCA as codes supporting medical necessity. Therefore, this test is not reasonable or necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare says for this test to be covered, there must be a bone 
marrow examination that is suggestive of myelodysplasia (MDS) and an inadequate cytogenetic assessment by 
conventional karyotyping. The records show that there is no documentation confirming the enrollee meets the 
requirements for approval of this test. Based on this information, we decided that Medicare rules for coverage 
of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve 
molecular cytogenetics; DNA probe, each (e.g., FISH) (88271).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S5501 and S9500 billed for date of service 
August 26, 2022, to August 31, 2022. 
 
You asked the Plan to pay for procedure codes S5501 and S9500. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the billed codes are invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes S5501 and S9500 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes S5501 and S9500 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes S5501 and S9500 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes S5501 and S9500 billed for 
date of service August 26, 2022, to August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 4, 2022, 
through May 10, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary. The Plan denied your request. The Plan says the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with confusion for one week. She 
had recently been started on antibiotics for a urinary tract infection two days prior. She was given intravenous  
antibiotics. She denied fever, chills, or dysuria. It was suspected that she may have had side effects from 
gabapentin use, so that was stopped. She was then given fluids. The enrollees vital signs were otherwise 
stable. Based on the workup not revealing a metabolic cause of her confusion, and as she was otherwise stable, 
it was not expected that the enrollee would require hospital services that would likely cross two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient hospital care provided from May 4, 2022, through May 10, 2022.
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 found a place that will work with the enrollee 
for ten days. You say the enrollee deserves a chance to continue their life. The Plan denied your request. The 
Plan says based on Medicare guidelines, the IRF services you are requesting 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the denial and are requesting reconsideration for the requested device. The Plan denied your request. The 
Plan says there is no mention of an adequate prior trial of a standard pneumatic compression device. The 
provider notes concern for possible increase in trunk swelling if a standard PCD is used. A standard device was 
reportedly briefly trialed during one therapy visit and deemed inappropriate. Based on the clinical submitted, 
criteria are not met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says total electric beds have extra features that are not needed at home. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
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 admission to IRF care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says based on the enrollee's current needs, we suggest care in 
a skilled nursing facility (SNF). 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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.