Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan 0.01% ophthalmic solution. 
 
You asked the Plan to pre-approve Lumigan. The Plan denied your request. The Plan says Lumigan 0.01% 
ophthalmic solution is a self-administered drug, and 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 Lumigan 0.01% ophthalmic 
solution.  
 
  Benefits for Lumigan 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 3 sensor. The Plan denied your request. The Plan says you 
do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have had an 
in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment 
plan. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 3 sensor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 3 
sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says denial of the LTACH admission is 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 23, 2022 to May 
22, 2022. 
 You asked the Plan to pay for home health services. You say that the services were provided, and payment 
should be rendered. The Plan denied your request. The Plan says the NOA lists the incorrect admission date of 
October 25, 2021. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 23, 2022. The NOA was received by the Plan May 6, 2022, but 
without the correct Bill Type or the correct admission date. Therefore, we decided that the Plan does not have 
to pay for home health services provided from April 23, 2022 to May 22, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria 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 clinical documentation shows that enrollee has functional impairments and some active medical issues, but no complex rehabilitation issues are specified (ambulating 100ft contact guard 
assist/supervision with most self-care tasks). Thus, the complexity of the enrollee's documented nursing, 
medical and rehabilitation needs would not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the left genicular 
nerve (64624). 
 
You asked the Plan to pre-approve an RFA of the left genicular nerve. You say that without this treatment, the 
enrollee will continue to have functionality issues. The Plan denied your request. The Plan says the criteria are 
not met because arthritis is not a temporary condition. 
 
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 RFA of the left genicular nerve. Our 
reviewer says that an RFA of the left genicular nerve is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the role of RFA of the genicular nerves is still under investigation and 
is the subject of ongoing clinical trials. 
 
 
  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 RFA of the left genicular nerve have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the left genicular nerve (64624).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87804 billed for date of service June 12, 
2022. 
 
You asked the Plan to pay for procedure code 87804. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 87804 is bundled into payment for code 87428. 
 
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 87804 
is a column II code to column I code 87428. 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 87804 billed for date of service June 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a quantitative differential pulmonary perfusion and 
ventilation (78598). 
 
You asked the Plan to pre-approve a quantitative differential pulmonary perfusion and ventilation. The Plan 
denied your request. The Plan says the enrollee does not have either of the clinical conditions that are indicated 
for coverage for this service. 
 
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 quantitative differential pulmonary 
perfusion and ventilation. Our reviewer says that a quantitative differential pulmonary perfusion and ventilation 
(78598) is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
record indicates that the enrollee has chronic obstructive pulmonary disease and obstructive sleep apnea. The 
record provided indicates that the enrollee is undergoing work up for increased shortness of breath with 
exertion. Our reviewer found that the record provided is insufficient to establish the medical necessity of the 
requested test at this time. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. Our physician reviewer also found that the elements of the 
coverage criteria are not satisfied, and the requested service is not 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 a quantitative differential pulmonary perfusion and ventilation have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a quantitative differential pulmonary 
perfusion and ventilation (78598).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 13, 2022, to July 21, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs. 
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 pay for SNF care provided from July 13, 2022, to July 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta (J2506). 
 
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says it was determined 
that the drug/regimen is not being prescribed for a medically accepted indication. 
 
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 Neulasta. Our reviewer says that 
Neulasta is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of the myeloid malignancy, acute myelogenous leukemia. The FDA 
has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and 
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 Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta (J2506).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from August 31, 
2021, to September 2, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that based on the information received, it does not support an acute inpatient stay. 
 
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. The plan has not provided any medical records to substantiate their denial for the 
inpatient stay. There is no evidence that the plan requested the records. Therefore, we decided that the Plan has 
to pay for inpatient hospital services provided to the enrollee from August 31, 2021, to September 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) and the other 
requested accessories/items (E0955, E0956, E1002, E1012, E1028, E2311, E2331, E2361, E2607, E2620). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the requested Group 3 power wheelchair and accessories exceed the enrollee's medical need and is not 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight 
capacity up to and including 300 pounds (K0856) and the other requested accessories/items (E0955, E0956, 
E1002, E1012, E1028, E2311, E2331, E2361, E2607, E2620).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 billed for date of service September 
20, 2021. 
 
You asked the Plan to pay for procedure code 64450. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 64450 is bundled into payment for code 64448. 
 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 64450 
is a column II code to column I code 64448. 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 64450 billed for date of service September 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
December 7, 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 the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. CPT code 99153 has a Professional 
Component (PC)/Technical Component (TC) indicator of 3 per the 2021 National Physician Fee Schedule 
Relative Value File October Release, we find that Medicare rule for payment of this claim has not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided 
on December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4556 billed for date of service February 26, 
2022. 
 
You asked the Plan to pay for procedure code A4556. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code A4556 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 A4556 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4556 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4556 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4556 billed for date of service February 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient behavioral health psychiatric admission. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that based upon a review of the records provided it was not expected this enrollee would improve in a reasonable period of time 
for the dates in question as she did not have suicidal or homicidal ideation. She had chronic auditory no visual 
hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or 
others and was compliant with her treatment. The health plans denial of continued inpatient psychiatric 
services is appropriate. 
 
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 an inpatient behavioral health psychiatric admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640, 87640, 87798, 87798, 87801, 87801, 
87503, and 87634 billed for date of service April 12, 2022. 
 
You asked the Plan to pay for procedure codes 87640, 87640, 87798, 87798, 87801, 87801, 87503, and 87632. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT codes 87640, 87640, 87798, 87798, 87801, 87801, and 87503 is 1. The MAI 
value for this code is 3. You billed 2 units of code 87640, 17 units of code 87798, 5 units of code 87801 and 2 
units of code 87503, exceeding the MUE. You did not provide all the required evidence showing that the 
excess units were actually provided, were correctly coded, and were medically necessary. 
 
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 87634 
is a column II code to column I code 87632. 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. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87640, 87640, 
87798, 87798, 87801, 87801, and 87503 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87640, 87640, 87798, 87798, 87801, 87801, 87503, and 87634 billed for date of 
service April 12, 2022.