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 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for weakness and biopsy of a brain mass. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen testing by nucleic acid provided on 
November 17, 2020. 
 
You asked the Plan to pay for the respiratory pathogen testing by nucleic acid. You say that this was medically 
necessary testing. The Plan denied your request. The Plan says the POS code reported does not match the 
location in which the sample was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 respiratory pathogen testing by nucleic acid 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 the respiratory pathogen testing by nucleic 
acid provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylphenidate ER tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Methylphenidate ER tablet is a self-administered drug. 
 
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 Methylphenidate ER tablet.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 you may benefit from PT, and OT, but you do not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. Your rehab can be safely provided at a lower intensity and alternate setting in a skilled 
nursing facility. 
 
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 the Freestyle Libre 2 reader device (CPT code K0554). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 does not show that the enrollee is administering 
insulin three (3) or more times per day or is using a Medicare-covered continuous subcutaneous insulin 
infusion (CSII) pump.  Based on this information, we decided that Medicare rules for coverage of the device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2 reader device (CPT 
code K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services provided on October 
26, 2021. 
 
You asked the Plan to pay for the medical nutrition therapy services. The Plan denied your request. The Plan 
says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
The records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan 
does not have to pay for the medical nutrition therapy services provided on October 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on May 6, 2021. 
 
You asked the Plan to pay for critical care, first hour. You say that this service was medically necessary and 
was billed appropriately. The Plan denied your request. The Plan says this code is not supported in the record, 
as the time spent providing this service is not noted. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no indication in the 
medical record of how long this service was provided on the date in question. Based on this information, we 
decided that Medicare rules for coverage of critical care, first hour have not been met. Therefore, we decided 
that the Plan does not have to pay for critical care, first hour (99291) provided on May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker (33274). 
 
You asked the Plan to pre-approve the leadless pacemaker. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested pacemaker is non-covered outside of a controlled 
study. 
 
The Plan must follow Medicare rules. Medicare rules say that Leadless pacemakers are non-covered when 
furnished outside of a CMS approved CED study. 
 
We looked at the file and Medicare rules. There is no documentation that the enrollee is enrolled in a controlled 
study or clinical trial. Based on this information, we decided that Medicare rules for coverage of the leadless 
pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve a leadless 
pacemaker (33274).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection of major joint (20611) with Genvisc (J7320) 
billed for date of service August 18, 2021. 
 
You asked the Plan to pay for an injection of major joint with Genvisc. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the provided medical records 
do not support the service 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. 
 
In this case, the CPT Code Manual definition of code 20611 is "Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting"; and the definition of code J7320 is "Hyaluronan or derivative, genvisc 850, for intra-
articular injection, 1 mg." 
 
We find that CPT codes 20611 and J7320 are not supported in the medical record. Specifically, the codes at issue were billed with modifier code "50," indicating a bilateral procedure. The provided medical records for 
the date of service at issue report an injection only into the left knee. Based on this information, we decided 
that Medicare rules for coverage of an injection of major joint with Genvisc have not been met. Therefore, we 
decided that the Plan does not have to pay for an injection of major joint (20611) with Genvisc (J7320) billed 
for date of service August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says a wheelchair is not needed for mobility in the home. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee would be able to ambulate with a cane. There is no documentation that the enrollee 
is unable to accomplish mobility-related self-care tasks without a cane or walker. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 4, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if no CPT code accurately describes the 
procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) 
with one unit of service.  
 
We looked at the file and Medicare rules. In this case, as there is no CPT that accurately described the testing 
performed, it is inappropriate to bill code 0239U for these services. Code 81479 would be appropriate in this case. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 4, 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 this is medically necessary. The Plan denied your 
request. The Plan says continued care could be better provided in an outpatient, skilled nursing facility, or long-
term care facility 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
observation on 3/16/22 for nausea, abdominal pain and vomiting and were discharged home. There is ongoing 
weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the provided records showed the enrollee cleared for surgery without 
expectation of a complication or a prolonged recovery. This procedure is typically completed as an ambulatory 
procedure. There was no suggestion from the provided notes that the enrollee would require hospital services 
that would likely cross 2 midnights related to this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Linzess 72mcg capsules. 
 
You asked the Plan to pre-approve Linzess. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
 
 
 
 
 
 
 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 Linzess 72mcg capsules.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that this is medically necessary. The 
Plan denied your request. The Plan says documentation does not support that there has been failure to respond 
to conservative care and does not support that you have been evaluated for non-facet pathology that could 
explain the source of the pain.  
The Plan follows Medicare rules. Medicare rules say that facet join injection services are subject to the 
indications listed 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 facet joint injection services. Our 
reviewer says that the requested facet joint injections are not medically reasonable and necessary. Our 
physician reviewer found you are an 84-year-old woman who has thoracic back pain. She has had intercostal 
nerve blocks, but the duration and degree of pain relief are not documented. She had a thoracic magnetic 
resonance imaging, but the details of the report are not documented. In this case, clinical practice guidelines 
state that the evidence in support is moderate but there is a very high false positive rate.  Further, the injections 
are not supported by imaging studies. At this point, therefore, the request is deemed 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 facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one hundred (100) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you receive dialysis 3 
days a week and you are on a kidney transplant list. You also say you are going to need additional trips to be 
able to go to your kidney transplant visits and regular doctor visits. The Plan denied your request. The Plan 
says your benefit only allows 60 trips per year. You have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  We looked at your request, the records in the case file, and the rules. The records show you have used 61 one-
way transportation trips this year. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve one hundred (100) additional routine transportation trips (A0120).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 30, 2021. 
 
You asked the Plan to pay for the ED services. You say that this was incorrectly denied as duplicate. The 
records support that this is payable. The Plan denied your request. The Plan says this was not denied as 
duplicate but was denied as the Plan is the secondary payer for this date of service. A claim must be filed with 
the primary payer, and the Explanation of Benefits can be submitted with a secondary payer claim if a balance 
remains. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the ED 
services until the primary insurer has processed the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the emergency department (ED) services provided on September 30, 2021.