Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on September 9, 
2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that this should be covered. The Plan denied 
your request. The Plan says the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an annual wellness visit was provided less than 12 months prior to the visit at issue 
in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) 
provided on September 9, 2022.
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 meets full criteria for IRF versus a lower 
level of care, rehabilitation goals are returning home independent as prior level of function. The Plan denied 
your request. The Plan says the medical records do not support the need for an intensive rehabilitation therapy 
program, medically necessary care maysafely be provided safely in a different level of 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 enrollee does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy 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 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's transfer is medical 
necessary. The Plan denied your request. The Plan says the enrollee may safely continue to receive care at the 
current hospital until discharge is medically appropriate. 
 
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 are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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 laboratory services (88377, 88189) provided on September 
22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says that the two diagnosis codes reported on this claim 
(C94.6 and D72.818) cannot be coded together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that an Excludes1 note indicates that the diagnosis code excluded should never be used at the same 
time as the code above the Excludes1 note. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, codes within the D72.8 code set (such as 
D72.818) have an Excludes1 note for all codes within the C91-C95 code set range. This means that D72.818 
cannot be reported with code C94.6. Therefore, we decided that the Plan does not have to pay for laboratory 
services (88377, 88189) provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular radiofrequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve RFA. You say that you were informed by the doctor's office that Medicare 
covers this because there is a procedure code assigned to it. The Plan denied your request. The Plan says the 
requested service is considered experimental. 
 
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 RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested RFA is considered experimental and investigational as it is currently the subject of clinical 
trials. Therefore, the reviewer found that the requested service is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a genicular radiofrequency ablation (RFA) (64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BRCA 1 and 2 Comprehensive Analysis Genetic 
Testing (81432, 81433). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial. The Plan denied 
your request. The Plan says screening genetic testing is not a covered benefit. You have no personal history of 
breast, ovarian, or pancreatic cancer. There is no documentation of any signs or symptoms of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the BRCA 1 and 2 comprehensive analysis genetic testing, is being requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pre-approve the BRCA 1 and 2 Comprehensive Analysis Genetic Testing 
(81432, 81433).
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 for the enrollee to be assessed both medically and 
functionally regarding their pre-morbid functional capacity. The Plan denied your request. The Plan says the 
enrollee's records do not show that it is reasonable to expect to safely participate in or fully benefit from the 
intensity of services of an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program, medically necessary care 
may 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: 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 needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for admission to an IRF. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0480) provided on June 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported as 
billed. 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) provided on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0483, 80307) provided on February 
18, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services are supported as billed. The Plan denied 
your request. The Plan says no order for these tests was provided; therefore, it cannot be confirmed that these 
services were medically necessary and ordered by the enrollee's treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, no order nor physician notes from the enrollee's treating physician were submitted for review. 
Without this documentation, we cannot confirm that the requested services were medically necessary and 
reasonable; nor can we confirm that these tests were ordered by a physician who is treating the enrollee. 
Therefore, we decided that the Plan does not have to pay for drug testing services (G0483, 80307) provided on 
February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that the pump is needed to 
prevent lymphedema and inflammation. You disagree with the denial. The Plan denied your request. The Plan 
says the requested device is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare rules confirm the requested pump is not a covered benefit 
with your Plan. Based on this information, we decided that Medicare rules for coverage of a fluid circulating 
cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
fluid circulating cold pad with pump (E0218).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography (CPT code 93458). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that they have had a heart transplant, or 
that the enrollee has unstable angina, a large perfusion defect, multiple moderate perfusion defects, or left 
ventricular dysfunction. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found guidelines do not support a need for invasive cardiac catheterization in this setting. As a result, 
at this time cardiac catheterization would not be considered medically appropriate and necessary in this 
enrollees clinical management.  
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve catheter placement in coronary artery(s) for coronary angiography (CPT code 93458).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compounded montelukast. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says compound montelukast sodium powder, starch powder rice, capsule 
coni-snap number 4 is a self-administered drug. The Plan states the medication does not fall under Part B 
coverage. 
 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 compounded montelukast.  
 
Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 20930. The Plan denied your request. The Plan says procedure 
code 20930 is considered bundled and not separately payable. 
  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 code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00103 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 00103. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the billed code has no corresponding payment amount. 
 
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 code 00103 has a Status Indicator of J on the Physician Fee Schedule. This means that 
procedure code 00103 has no relative value units or payment amounts and is only used to facilitate the 
identification of anesthesia services. Based on this information, we decided that Medicare rules for coverage of procedure code 00103 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 00103 billed for date of service August 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to regain strength so you may return 
home safely. The Plan denied your request. The Plan says as the enrollee recovers from this surgery, some 
assistance needed at discharge would be custodial care. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 13131 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 13131. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 13131 is bundled into payment for code 13132. 
 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 13131 
is a column II code to column I code 13132. 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 13131 billed for date of service April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS system (C2624 and 33289). 
 
You asked the Plan to pre-approve the system. You say that the enrollee needs this device and procedure due to 
worsening heart failure. The Plan denied your request. The Plan says the enrollee's records do not show that 
theyhave New York Heart Association Class III heart failure or that they are registered in a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS system (C2624 and 33289).