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 the enrollee's medical management requires an IRF 
stay and close physician supervision. The Plan denied your request. The Plan says IRF care 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple procedures on the 
date in question. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that the 
requirements for coverage of Injectafer have not been met. Our physician reviewer found the Plan requires a 
trial of Infed (iron dextran) and Venofer (iron sucrose) before they will approve Injectafer. The provided 
records do not document that the enrollee has tried and failed these drugs. They also do not document that these 
drugs would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.  Specifically, the acupuncture services in this case were not requested on the basis of a diagnosis for chronic 
low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 29, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 29, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop records is used when syncope is 
thought to be cardiac-related, but is too infrequent to be detected by either a Holter monitor or a traditional pre-
symptom loop recorder. 
 
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 implantable loop recorder. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found the enrollee had no 
history of atrial fibrillation, nor were any significant cardiac arrhythmia noted on electrocardiogram 
monitoring. The records do not support the service. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip x-ray (CPT code 73501) provided on June 14, 2022. 
 
You asked the Plan to pay for the hip x-ray. You say that the claim should be paid. The Plan denied your 
request. The Plan says CPT code 73501 was not billed in accordance with Medicare National Correct Coding 
Initiative Policy Medically Unlikely Edits (MUE). 
 
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 hip x-ray have not been met. CPT code 73501 has an MUE 
value of 2 and was billed for three (3) units; however, one (1) unit was paid. Therefore, the one unit that was 
paid is the only unit covered. Therefore, we decided that the Plan does not have to pay for the hip x-ray (CPT 
code 73501) provided on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 28, 2021, to January 6, 2022. 
 
You asked the Plan to waive the copayment for inpatient care. You say that this charge shuold be removed. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $100 copayment per day for days 1 to 7 for inpatient stay. This inpatient stay lasted 9 days, resulting 
in a copayment amount of $700. 
 
The enrollee has been asked to pay $100 copayment per day for days 1 to 7 for inpatient care. This item/service 
falls within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided from December 28, 2021, to January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and appliance 
(E0673) provided on June 1, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. 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 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. In addition, pneumatic compression devices are not 
covered by Medicare when the place of service is an ambulatory surgical center. The Place of Service billed 
was 24, which is an ambulatory surgical center. Medicare rules state that for durable medical equipment to be 
covered, it must be appropriate and be needed for use inside the home Therefore, we decided that the Plan does 
not have to pay for a pneumatic compression device (E0676) and appliance (E0673) provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair or nonroutine service for durable medical 
equipment (K0739). 
 
You asked the Plan to pre-approve the repair or nonroutine service for durable medical equipment. You say 
that the service is medically necessary. The Plan denied your request. The Plan says there is no documentation 
showing what repairs needed and the cost of the repairs needed. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 the repair or nonroutine service for 
durable medical equipment have been met. There is no documentation showing what repairs needed and the 
cost of the repairs needed.. Therefore, we decided that the Plan does not have to pre-approve the repair or 
nonroutine service for durable medical equipment (K0739).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, 5-21 drug classes (G0482) 
provided August 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support the necessity 
of the service in dispute. The Plan denied your request. The Plan says records do not support the service billed.  
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 the laboratory services have been met. 
The provided records contain discrepancies with the reported referring physician noted on the submitted claim 
form. The submitted lab requisition contained provider credentials from one provider, however it did not match 
with the reported referring physician noted on the submitted claim form. The Plan made multiple attempts to 
obtain the additional information without success. Therefore, we decided that the Plan does not have to pay for 
the definitive drug testing, 5-21 drug classes (G0482) provided August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and accessory 
provided on August 8, 2022. 
 
You asked the Plan to pay for the PCD and accessory. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and accessory provided on August 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22514). 
 
You asked the Plan to pre-approve a kyphoplasty procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is 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 a kyphoplasty procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the imaging studies show bone retropulsion, which is a contraindication to kyphoplasty. 
 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 kyphoplasty procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on July 9, 
2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
submitted did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain medical records which support medical necessity for the supplies provided in this 
case. The records provided indicate that the enrollee has chronic pain syndrome with low back pain. However, 
the records do not indicate any intent to provide TENS and supplies. Therefore, we decided that the Plan does 
not have to pay for the electrical stimulator supplies (A4595) provided on July 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Sandostatin LAR Depot. 
 
You asked the Plan to pre-approve Sandostatin LAR Depot. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed 
for an off-label, not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Sandostatin LAR Depot. Our reviewer 
says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a diagnosis of iron deficiency anemia secondary to multi-factorial causes. The FDA 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sandostatin LAR Depot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve treatment with Sandostatin LAR Depot.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the inpatient rehabilitation facility (IRF) 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee has a major spinal cord injury and requires a complex and 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 the laboratory services related to end-stage renal disease 
(ESRD) provided on June 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these tests were medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 8, 
2022.