Persius/hicric huggingface dataset:
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 need to be monitored. The Plan denied your 
request. The Plan says based on Medicare guidelines and the information we have about your condition you 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 admitted to an acute hospital on September 21, 2022, with an intra-
abdominal infection and purulent drainage from drain site with an intraabdominal abscess. As of September 30, 
2022, you are medically stable. There are no complex nursing or rehabilitation needs. While you have 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: 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 needs LTACH care. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not 
meet the requirements for approval. 
 
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 in this case the documentation does not support that the enrollee has need for 
complex medical treatment in a LTACH. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility. The requested treatments are not medically 
necessary at the LTACH level of care. The enrollee has improved medically but continues to require care at the 
acute care hospital. The enrollee can receive further care at the current acute care hospital or a lower level of 
care when deemed 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs the more aggressive 
rehabilitation that the LTACH gives so they can maximize their progress. The Plan denied your request. The 
Plan says that the enrollee does not meet the guidelines for LTACH admission, and they are receiving 
medically necessary care at the current facility they are at. 
 
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 appears to be improving but still somewhat unstable and should only 
require short-term additional acute care services that can be safely administered at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current facility. There are no services at the LTACH that the patient requires 
that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as the enrollee is unstable for transfer and as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says the records show this scooter is for use outside the home. 
Coverage rules have not been met. 
 
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 pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedence spectroscopy. 
 
You asked the Plan to pre-approve bioimpedence spectroscopy. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 bioimpedence spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bioimpedance spectroscopy measures the differential impedance 
(resistance) to low level electrical current to evaluate changes in body fluid composition that occur in 
conditions such as lymphedema. The reviewed literature states there is insufficient evidence that this 
technology is effective. The review has determined that the items/services at issue in this case are not medically 
reasonable or 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 bioimpedence spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedence spectroscopy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 19, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 81455 is not supported in the medical record. Specifically, the claim must 
be billed with the date the specimen was collected. The records show that the specimen was collected on April 
8, 2022. As such, the claim was billed with the incorrect date of service. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), multiple organisms (87801), infectious agent detection by nucleic acid (DNA or RNA), not otherwise 
specified (87798), and Infectious agent detection by nucleic acid (DNA or RNA); Candida species (87481) 
provided on March 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services in this case were medically 
necessary. The Plan denied your request. The Plan says the services in this case are not medically reasonable or 
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 pay for the laboratory services. Our reviewer says 
that the laboratory services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found polymerase chain reaction (PCR) testing is not supported as a first line approach for evaluation 
of nail disorders and it is not widely accepted as standard of care. The testing services exceed the enrollee's 
medical needs. Therefore, the reviewer found that the laboratory services were not medically reasonable or 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA), multiple organisms 
(87801), infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified (87798), and 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species (87481) provided on March 23, 
2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasound of the abdominal aorta (76706) provided on March 3, 
2022. 
 You asked the Plan to pay for the ultrasound. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have been met. Specifically, the service was billed with CPT code 76706 as directed 
by Medicare guidelines. This service was billed with a screening diagnosis, and there are no Medicare criteria 
regulating what diagnosis codes must be billed for this service. Therefore, we decided that the Plan has to pay 
for the ultrasound of the abdominal aorta (76706) provided on March 3, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from  
May 8, 2022, to June 6, 2022. 
 You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says continuation of SNF 
services does not meet the Medicare coverage criteria. 
 
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 as of May 8, 2022 the enrollee did not require any skilled nursing or 
rehabilitation services on a daily basis. The enrollee was not expected to make measurable gains within a 
reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or 
activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective 
maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient 
basis as of May 8, 2022. The enrollee did not have any parental medications, complex wound care or nutrition 
given via a feeding tube. The enrollee received skilled care and improved; however, her functional 
improvement had plateaued by May 8, 2022 and she did not require any further inpatient skilled rehabilitation 
services. The enrollees function was at or near her prior level of function and she could be discharged to a 
lower level of care for further services. As of May 8, 2022 the enrollee required custodial services.  
 
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 May 8, 2022 to June 6, 2022.
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 the requested service. You say that you do have limited mobility. The Plan 
denied your request. The Plan says coverage requirements have not been met. 
 
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 looked at the file, and Medicare rules. The records show that your range of movement is within normal 
limits. The records do not show that you are completely unable to stand up from a regular chair. Based on this 
information, we decided that Medicare rules for coverage of the requested service have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have complex or specialized rehabilitation needs and does not 
require frequent physiatry oversight. The enrollee has no unstable co-morbid conditions requiring frequent 
review or assessment. 
 
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 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 the enrollee has functional impairments and would 
benefit from skilled therapy. However, neurology recommends follow-up as an outpatient. Thus the enrollee would not be expected to require continued inpatient hospitalization. IRF criteria have not been met 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 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 swing arm wheelchair. 
 
You asked the Plan to pre-approve a swing arm wheelchair. You say that the swing arm broke on your 
wheelchair. The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair that was provided by the Plan in June 2021. Your current 
power wheelchair serves the same purpose as the requested manual wheelchair. The Plan has noted that if your 
medical needs have changed, your physician needs to refer you to the mobility clinic to be re-evaluated. 
Therefore, we decided that the Plan does not have to pre-approve a swing arm wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical alert system. 
 
You asked the Plan to pre-approve a medical alert system. You say that you keep falling and have no family to 
help you. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that that telephone alert systems are emergency communications systems 
and do not serve a diagnostic or therapeutic purpose. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. A telephone alert 
system does not serve a diagnostic or therapeutic purpose. Therefore, we decided that the Plan does not have to 
pre-approve a medical alert system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77067 billed for services provided on 
February 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on March 25, 2021. Comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date. Based on this information, 
we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 77067 billed for services provided on February 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 7, 2022 billed with 
codes 81225,81226,81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. 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 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 genetic testing provided on 
April 7, 2022 billed with codes 81225,81226,81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 
0031U, 0032U, and 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01214) provided on May 18, 2022. 
 
You asked the Plan to pay for procedure code 01214. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 anesthesia services (01214) 
provided on May 18, 2022, have been met. In this case, there were no medical records provided confirming that 
two separate anesthesia services (01214) were provided May 18, 2022, by this provider. The file shows that the Plan paid for one claim submitted with code 01214 by this provider. Therefore, we decided that the Plan does 
not have to pay for the anesthesia services (01214) provided on May 18, 2022.