Persius/hicric huggingface dataset:
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee appears to still be unstable and requires short-term additional acute care 
services that can be safely administered at the current facility until more stable and weaning potential is clearer. 
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
 
 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 31, 2022. 
 
You asked the Plan to pre-approve SNF care after March 31, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 pre-approve SNF care after March 31, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/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 after March 31, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet criteria for the requested CGM. 
 
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 use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided December 31, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has been billed with an incorrect 
place of service code. 
 
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 laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided December 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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. You 
have no new medical problems, are medically stable and do not need physical medicine and rehabilitaiton physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. 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. 
You will not be able to make a significant functional recovery with confusion in an IRF and retain the learned 
functional skills. At the current level of function, your rehab can be safely provided at a lower intensity and 
alternate setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology screening testing provided on April 21, 2021. 
 You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this testing was done for 
screening purposes which is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, lab test, was requested for screening purposes. Medicare does not cover this test 
for screening purposes. Therefore, we decided that the Plan does not have to pay for cytopathology screening 
testing provided on April 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox for the enrollee. 
 
You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Botox in the setting of perioperative 
management of hernia repair has not been demonstrated in the peer-reviewed literature. 
 
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 Botox. Our reviewer says that Botox is 
not medically reasonable and necessary. The clinical value and effectiveness of Botox in the setting of 
perioperative management of hernia repair has not been demonstrated in the peer-reviewed literature. The 
requested use of Botox is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the 
major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services have been billed with an 
incorrect place of service. 
 
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 laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says genetic testing procedures submitted with 
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and 
will be denied. 
 
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 provided on 
October 15, 2021, have been met. In this case, no clinical records were submitted to support the medical 
necessity of the provided genetic testing services or how these services would assist with handling the 
enrollees condition. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the requested procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the panel testing services provided on November 23, 
2021. 
 
You asked the Plan to pre-approve the testing services. The Plan denied your request. The Plan says the testing 
is considered unproven. 
 
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 testing services. Our physician 
reviewer found that the enrollee has a history of post-coital hematuria. His urine sample was sent for panel 
testing. The reviewed documentation does not support why a reflex culture and sensitivity was not performed. 
The clinical value of the provided testing for urinary tract infections remains unproven in the literature. The 
obtained labs were not medically reasonable or necessary above the standard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the panel testing services provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair (E1038) for use only outside the home. 
 
You asked the Plan to pre-approve a transport chair. You say that you only need the transport chair so your 
daughter can help you when you go outside the home to appointments. The Plan denied your request. The Plan 
says a transport chair is not covered by Medicare or the Plan for use only 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 pre-approve a transport chair (E1038) for use only outside the home.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing lab services (81455) provided on September 
9, 2021. 
 
You asked the Plan to pay for genetic testing lab services. You say that you would like this claim reprocessed 
as medically necessary for the enrollee's condition. The Plan denied your request. The Plan says genetic testing 
procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical 
management of the patient. 
 
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 genetic testing lab services (81455) 
provided on September 9, 2021, have been met. In this case, no clinical records have been submitted that 
indicate why the requested genetic testing services were requested for treating the enrollees condition. 
Therefore, we decided that the Plan does not have to pay for genetic testing lab services (81455) provided on 
September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75822-59 billed for date of service 
September 28, 2021. 
 
You asked the Plan to pay for procedure code 75822-59. You say that the medical records support payment for 
the services billed. The Plan denied your request. The Plan says the use of the -59 modifier is not substantiated 
in the medical record. As a result, payment for code 75822-59 is inclusive to code 37238-RT performed on the 
same date. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 75822-59 Our reviewer says 
that use of the -59 modifier is not supported by the medical record. Our physician reviewer found your appeal 
letter notes that several procedures were performed in this case. However, in order to bill separately for the 
radiological services, the radiological services must be diagnostic prior to intervention. This is not supported in the procedure report, and therefore would not be reported separately from the transcatheter placement which 
includes radiological 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 procedure code 75822-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 75822-59 billed for date of service September 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance service (A0428) and ground 
mileage (A0425) provided on December 22, 2020. 
 
You asked the Plan to pay for the non-emergency ambulance service and ground mileage. You say that you 
would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says there was no 
documented acute, urgent, or emergent condition. The Plan also says that van transport or other vehicle, or 
home visit, may have been an option. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance service and 
ground mileage. Our reviewer says that the documentation does not support that the ambulance transport on 
December 22, 2020 was medically reasonable and necessary for the patient. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van) were 
contraindicated for this patient. Our reviewer also found that the documentation does not support that the 
patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport on December 22, 2020. 
 
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 non-emergency ambulance service and ground mileage have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance service (A0428) 
and ground mileage (A0425) provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation evaluation and management services (99217, 
99225, 99219) provided from October 2, 2021, through October 4, 2021. 
 
You asked the Plan to pay for the observation evaluation and management services. You say that you believe 
that these services should be covered as medically necessary. The Plan denied your request. The Plan says this 
claim has denied as the services billed have been found to be unbundled according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same 
physician or more than one physician in the same specialty in the same group, only one evaluation and 
management service may be reported unless the evaluation and management services are for unrelated 
problems. 
 
We looked at the file and Medicare rules. In this case, multiple evaluation and management services were 
billed on the same day. The Plan has paid the inpatient evaluation and management services but is not 
responsible for the outpatient evaluation and management services. Based on this information, we decided that 
Medicare rules for coverage of the observation evaluation and management services have not been met. 
Therefore, we decided that the Plan does not have to pay for the observation evaluation and management 
services (99217, 99225, 99219) provided from October 2, 2021, through October 4, 2021.