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

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM). 
 You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee did not meet 
criteria for the items rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies 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 use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the supply 
allowance for therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan 
does not have to pay for the supply allowance for therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service  
January 18, 2022. 
 
You asked the Plan to pay for procedure code 11721. The Plan denied your request. The Plan says payment for 
code 11721 is bundled into payment for code 11055. 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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service  
January 18, 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 these services are medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission has not been met. 
 
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 no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. The member can receive further services at a lower 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Radicava ORS Starter Suspension. 
 
You asked the Plan to pre-approve Radicava ORS Starter Suspension. You say that the records provided 
support the need for the requested drug. The Plan denied your request. The Plan says the requested medication 
does not fall under Part B coverage. The Plan says that the enrollee does not have pharmacy benefits 
administered under this contract. 
 
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 Radicava ORS Starter 
Suspension.  
 Benefits for Radicava ORS Starter Suspension 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: 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 are requesting a reconsideration. The Plan 
denied your request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility 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 you were chronically deconditioned and now more so after surgery. As of September 
12, 2022 you cannot tolerate intensive rehabilitation due to low blood pressure.  You do not have complex rehabilitation needs related to your medical needs or your function status. You do not 
require frequent physiatry oversight. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
July 10, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). The Plan denied your request. The 
Plan says the submitted discharge summary does not support hospital discharge day management of more than 
30 minutes was performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
  We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not document 
discharge management services of more than 30 minutes, as required by the CPT code billed. Based on this 
information, we decided that Medicare rules for coverage of hospital discharge day management (99239) have 
not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management 
(99239) provided on July 10, 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 you need intense rehab is needed to help you return 
to your prior level of function the safest and quickest way. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary. 
 
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 enrollees needs may reasonably be met at a lower level of care consistent with prevailing clinical practice and evidence-based standards for post-acute rehabilitation. 
 
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 the lab testing services provided on March 28, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code cannot 
be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing, which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab testing services provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for services on January 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that the lab does not require an active medical/state 
license. The Plan denied your request. The Plan says the requested documents have not been submitted. 
 
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. We find that the billed services are not supported. There are no lab 
reports or medical records to show the billed services were provided. The Plan made multiple attempts to 
obtain the information, without success.  Based on this information, we decided that there is insufficient information in the record to determine if 
Medicare rules for coverage of have been met. Therefore, we decided that the Plan does not have to pay for the 
lab testing billed for services on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81286, 81413, 81414, 81442, 81161, 81479) 
provided January 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 lab services (81286, 81413, 81414, 
81442, 81161, 81479) provided January 7, 2022. have been met. No clinical records were provided to support 
the lab services performed. Therefore, we decided that the Plan does not have to pay for lab services (81286, 
81413, 81414, 81442, 81161, 81479) provided January 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9503 billed for date of service April 21, 
2022, to April 27, 2022. 
 
You asked the Plan to pay for procedure code S9503. The Plan denied your request. The Plan says the billed 
code is 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 code S9503 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9503 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9503 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9503 billed for date of service April 21, 2022, to April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive diabetes panel provided on September 9, 
2021, billed with codes 81406, 81407, 81479, 81404, 81405, 81403 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and should 
be paid in full. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive diabetes panel provided on September 9, 2021, billed with codes 81406, 81407, 81479, 81404, 81405, 81403 and 
81401.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is currently being treated for high-grade 
carcinoma of unknown site, p53 positive, Ki-67 80%, but primarily concerns regarding genitourinary origin as 
renal, urothelial as the origin. You say that the records provided support the need for the requested treatment. 
The Plan denied your request. The Plan says the requested treatment plan is unproven to be treatment for the 
enrollee's cancer. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested drug is not FDA-approved 
for the enrollee's diagnosis when used in conjunction with carboplatin and gemcitabine. The use of Keytruda 
along with these other drugs is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Chemotherapy immunotherapy is not approvable per literature and the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 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. 
 
Review of the file shows that no medical records were provided to support the services billed. This means that 
the documentation does not support that the laboratory testing at issue in this appeal was not 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 pay for the laboratory services provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the measurement of post-voiding residual urine and/or 
bladder capacity by ultrasound (51798), and hospital outpatient clinic visit (G0463) provided on April 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the enrollee did not disclose that they had 
switched plans when they scheduled their appointment. The Plan denied your request. The Plan says the claim 
denied correctly. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the measurement of post-voiding residual urine and/or bladder 
capacity by ultrasound (51798), and hospital outpatient clinic visit (G0463) provided on April 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on June 9, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 provided on September 1, 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 you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says criteria for admission to 
the acute inpatient rehabilitation setting have not been met. The enrollee's ongoing skilled therapy and nursing 
needs can be provided at a lower level of care such as at a skilled nursing facility, on an intermittent basis at 
home with home health care, or in a long-term care setting. 
 
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 has a history of Parkinson's Disease, depressive disorder, 
hypersensitivity lung disease, chronic benzodiazepine therapy, breast cancer with recurrence for the third time 
and recent surgery with a chemotherapy plan was admitted to acute hospital on September 9, 2022 with a 
urinary tract infection and generalized weakness. The September 15, 2022 progress note - the enrollee is 
clinically unchanged, no major medical issues at this time. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
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. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 there is no documentation that the 
enrollee has severe neuromuscular disease or that she is incapable of standing up from a regular armchair or 
any chair in the home. The criteria for coverage are not met and the requested seat lift mechanism is not 
reasonable or 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 a seat lift mechanism.