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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF care. 
 
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 patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient 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: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the individual psychotherapy services (90832) provided October 26, 
2021. 
 
You asked the Plan to pay for psychotherapy services. You say that please review and process the claim 
towards payment. The Plan denied your request. The Plan says that the listing of a referring provider on the 
claim does not satisfy the documentation criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have been met. Specifically, the record shows that the enrollee was referred 
to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay for the 
individual psychotherapy services (90832) provided October 26, 2021.  
 
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 (81162, 81317, 81319, 81203, 81300, 81323, 
81351, 81307) provided June 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed share a bundled relationship with other codes billed. 
 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 codes 
81162, 81317, 81319, 81203, 81300, 81323, 81351, 81307 share a bundled relationship with codes81435 & 
81319. 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 lab services (81162, 81317, 81319, 81203, 81300, 81323, 81351, 81307) provided June 11, 2021.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were evaluated in the 
Emergency Department on March 2, 2022, for a groin wound and lower extremity edema and was discharged 
home. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has had a relapse thyroid papillary 
cardio cancer with pleural effusion and perihilar mass. The Plan denied your request. The Plan says the 
documentation does not support that the enrollee has: an accepted medical indication for the use of Keytruda. 
The Plan states the use of this drug in the enrollee's case requires TMB-H status and there is no documentation 
of this status in records submitted. 
 
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 medication. Our physician reviewer 
found the requested use of Keytruda is not FDA-approved for the enrollees diagnosis. The use is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal 
(see appendix for list of CMS-approved journals). 
 
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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (CPT code J9271).
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 additional routine transportation trips. You say that you need additional 
transportation to get to your dialysis appointments. The Plan denied your request. The Plan says that additional 
routine transportation is not covered. 
 
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 thirty-six (36) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to cover routine transportation above the benefit maximum of thirty-six (36) routine 
transportation trips. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on August 17, 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 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the anesthesia services provided on 
June 22, 2020. 
 
You asked the Plan to make additional payment for the anesthesia services. You say that this should not be 
denied because the claim was submitted within the allowed time frame. The Plan denied your request. The Plan 
says this claim was not received until more that one year after the date of service. As such, it was correctly 
denied as untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the anesthesia services was not filed until October 29, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to make additional payment for the anesthesia services provided on June 
22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) segmental 
pneumatic appliance (E0673) provided August 11, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that these services are 
not paid to you by the facility and payment for these items used should not be included with payment to the 
facility as you bill charges separately for services provided under a DME license. The Plan denied your request. 
The Plan says items that are used for preventative service or function are excluded from coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) segmental pneumatic appliance (E0673) provided August 11, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (75774, 75726) provided on April 8, 2021. 
 
You asked the Plan to pay for the service. The Plan denied your request. The Plan says these are bundled 
services. 
 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 75774 
and 75726 is a column II code to column I code 37243. 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 the services (75774, 75726) provided on April 8, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the allergy skin testing (CPT code 99204) to be 
performed by an allergist. 
 You asked the Plan to pre-approve the services. You say that you have hives and have tried medication which 
is not working. The Plan denied your request. The Plan says you have been approved to see an allergist to 
determine the best test to perform. The Plan states after seeing you, the allergist can determine what tasks are 
appropriate and submit a request for them. The Plan states that skin testing is not the only type of allergy 
testing that can be performed. 
 
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 services. physician reviewer found 
the review has determined that you have been approved to see an allergist. This allergy test was submitted by 
the primary care physician based on an office visit at the request of you. It is unknown whether this type of skin 
testing is necessary, or a patch test, or a sublingual allergen test. For chronic urticaria, a history and possible 
elimination diet might be appropriate for steps. Allergy testing may be appropriate, but it is best that the 
allergist determine that after their examination rather than the member requesting that the primary care 
physician put in a referral for allergy testing. The medical records provided do not meet the requirements listed 
in the LCD for Medicare coverage. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve the allergy skin testing (CPT code 99204) to be performed by an allergist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; other 
peripheral nerve or branch (CPT code 64450-59) provided on July 20, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this code is included in CPT code 01610; therefore, it cannot be separately reimbursed. The Plan 
states the billed CPT code and modifier 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. 
 
 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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. Documentation is not legible, and therefore this procedure cannot be 
verified, if the anesthetic agent was part of the primary anesthesia or for post pain management which would be 
a separately reported service. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch (CPT code 
64450-59) provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 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 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 these 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 laboratory services rendered on May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal system and alignable system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of peripheral 
artery disease and a left-sided below the knee amputation. The documentation does not support that the 
enrollee's past history, current status of the residual limb, the nature of the other medical problems, and desire 
to ambulate do not support that the separate endoskeletal system and alignable system are reasonable and 
medically necessary. 
 
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 pre-approve an endoskeletal system and alignable system.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428-
HN, A0425-HN) provided on October 19, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were not included in the 
skilled nursing facility (SNF) billing and should be paid. The Plan denied your request. The Plan says the 
enrollee was admitted to a skilled nursing facility at the time of services, and the payment for this transport is 
included in the SNF Prospective Payment System (PPS) rate. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that ambulance transport is included in the SNF PPS rate if the first or second character 
(origin or destination) of any HCPCS code ambulance modifier is N. In this instance, the SNF is responsible 
for the costs of the transport. 
 
In this case, the enrollee was admitted to a skilled nursing facility from October 11, 2021, to October 31, 2021. 
The enrollee received non-emergent ambulance transportation services on October 19, 2021, which were billed 
with destination modifier N. This means that this ambulance transport would be included in the SNF PPS 
rate and would not be paid separately by the Plan. Based on this information, we decided that Medicare rules 
for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for the non-emergent ambulance transportation services (A0428-HN, A0425-HN) provided on October 19, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF care. 
 
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 patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient 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.