Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bi-Level Positive Airway Pressure (BiPAP) device 
(E0470) and supplies (A7035, A7036, A4604, A7030, A7039, A7028, A7029, A7031, A7032, A7033, A7038, 
E0562). 
 
You asked the Plan to pre-approve a BiPAP device. You say that you disagree with the denial. The Plan denied 
your request. The Plan says you do not meet coverage criteria for approval of the BiPAP device. 
 
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 a BiPAP device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have COPD, supported by imaging, but there are no pulmonary function tests to assess 
severity. The records show an ABG from 7/30/2020, with mild CO2 retention, but the circumstances are not 
provided. You were hospitalized on 9/8/22 for a COPD exacerbation. ABG showed normal pH and PaCO2. 
BiPAP was prescribed at discharge. It appears you do not have chronic CO2 retention based on the most recent 
ABG. Utilization of BiPAP from 10/11/2022 to 1/8/2023 was 62% of days for at least 4 hours, which does not 
meet minimum Medicare criteria of at least 70% of days. 
 
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 BiPAP device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Bi-Level Positive Airway Pressure (BiPAP) device (E0470) and supplies (A7035, 
A7036, A4604, A7030, A7039, A7028, A7029, A7031, A7032, A7033, A7038, E0562).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 87086 for date of service June 
27, 2022. 
 
You asked the Plan to pay for code 87086. You say that this is a covered test. The Plan denied your request. 
The Plan says you did not bill with an appropriate diagnosis for this service. The Plan must follow Medicare 
rules. Medicare rules say that code 87086 is coverable when billed with an approved diagnosis. The Change 
Report referenced in the rules section lists all of the approved diagnoses for this lab test.  The sole diagnosis 
code that you billed on this claim (D41.01) is not listed as a covered diagnosis for this service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 87086 have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services billed with code 87086 for date of service June 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on June 3, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed services cannot be verified. 
 
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 the denied codes is: 
 
CPT 97110: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and 
endurance, range of motion and flexibility 
 
CPT 97112: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 
 We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 97110, the 
medical record does not include documentation of a therapeutic exercises to develop strength and endurance, 
range of motion and flexibility, each 15 minutes. In this case, this procedure cannot be verified, as service was 
not documented. For CPT 97112, the medical record does not include documentation of neuromuscular 
reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting 
and/or standing activities, each 15 minutes. In this case, this procedure cannot be verified, as service was not 
documented. 
 
We looked at this coder's review, the file, and Medicare rules. 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 physical therapy services provided to the enrollee on June 3, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard. 
 
You asked the Plan to pre-approve Gammagard. 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. 
 
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 Gammagard. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug. There is no documentation provided indicating that the Plans required drug would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services, provided on February 13, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says that the provider was not enrolled with Medicare. 
 
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. Documentation showing temporary Medicare enrollment for the public health 
emergency was granted, and the Plan has not provided any evidence it was not valid on the date of service. 
 
 Therefore, we decided that the Plan has to pay for the emergency room services, provided on February 13, 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 8, 2021 to 
November 13, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 418. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the documentation does not consistently and completely support the assigned secondary 
diagnosis code. The decision to remove the secondary diagnosis code and adjust the DRG is upheld. The 
documentation does not indicate that the diagnostic work-up and treatment ordered by the treating medical 
providers supported a diagnosis code E87.1 (hyponatremia).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 8, 2021 to November 13, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
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. The Plan denied your request. The Plan says the service requested 
is not supported based on the records we received. Based on the enrollee's current needs, the Plan suggests care 
in a skilled nursing facility. 
 
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 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: 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 enrollee currently meets the LTACH 
admission criteria. The Plan denied your request. The Plan says LTACH services are not medically necessary, 
and the enrollee may remain in the current acute care location. When the enrollee is medically stable and no 
longer requires an acute level of care, the enrollee's ongoing needs may be completed safely in a lower level of 
care such as an inpatient rehabilitation facility or even a skilled nursing facility. 
 
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 continues to receive acute care services and these have not been denied.  
The medical record does not indicate that the enrollee requires services that the enrollee is not currently 
receiving but that would be available at the LTACH 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 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: 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 would benefit from acute rehabilitation 
to optimize her level of functioning prior to returning home. The enrollee has a serious, life-threatening 
constellation of acute medical problems that have left her at a functional status below her baseline. The Plan 
denied your request. The Plan says the enrollee does not need specialized training, staff, or equipment available 
only in an IRF and does not have a medical complexity that needs many doctor visits in an inpatient 
rehabilitation facility. The enrollee's needs may be met safely in an alternate level of care for example a skilled 
nursing facility. 
 
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 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 safely 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the routine transportation beyond the Plan's 50-mile trip 
limit. 
 
You asked the Plan to pre-approve the routine transportation beyond the mileage limit. You say that you need 
to go to this provider for care for back pain. The Plan denied your request. The Plan says the requested trip 
exceeds your mileage limit. 
 
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 routine transportation up to 50 miles per one-way trip. 
 We looked at your request, the records in the case file, and the rules. In this case the requested trip exceeds 50 
miles of driving distance. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve the routine 
transportation beyond the Plan's 50-mile trip limit.
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 enrollee is stable and safe for 
discharge to a LTACH that will improve the enrollee's condition. The Plan denied your request. The Plan says 
the enrollee's continued care needs may safely be met at their current acute care facility. 
 
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 medical records does not indicate that the enrollee requires services in a LTACH 
that are currently being received at their current acute care facility. The requested service cannot be 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88344 billed for date of service July 28, 
2022. 
 You asked the Plan to pay for procedure code 88344. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 88344 is bundled into 
payment for code 88360. 
 
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 88344 
is a column II code to column I code 88360. 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 88344 billed for date of service July 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service October 
7, 2022. 
 
You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
October 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xT solid tumor panel provided to the enrollee on March 10, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the test does not meet Medicare standards and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has stage IV pancreatic cancer. This test should be covered to look for actionable 
mutations, such as MLH1, MSH2, MSH6, PMSA2, EPCAM, MTRK, BRCA 1/2. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
the Tempus xT solid tumor panel provided to the enrollee on March 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99217 billed for date of service May 7, 2022. 
 
You asked the Plan to pay for procedure code 99217. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99217 is bundled into payment for code 99220. 
 
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 99217 
is a column II code to column I code 99220 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99217 billed for date of service May 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested procedure is unproven and not medically necessary and are 
not covered by Medicare or the Plan. 
 
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 an 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 and investigational. More research is needed 
due to insufficient evidence of efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).