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 be more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until appropriate for a 
lower level of care. 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 at this time. Completion of treatment at the current location 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Omeprazole.
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services (90999) provided January 2, 2021 to January 30, 2021.
You asked the Plan to pay for the dialysis services. You say that this service was medically necessary. The Plan denied your request. The Plan says payment for this service is included in payment for the primary dialysis procedure.
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 90999 is unlisted dialysis procedure, other. 
We find that CPT code 90999 is not supported in the medical record. Specifically payment for this service is included in payment for the dialysis procedure. This code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for dialysis services (90999) provided January 2, 2021 to January 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0483) provided on October 20, 2021.
You asked the Plan to pay for code G0483. 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 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. 
In this case, the CPT Code Manual definition of code G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 22 or more drug classes was performed. Therefore, we decided that the Plan does not have to pay for the drug testing (G0483) provided on October 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled nursing facility (SNF) care 
 
You asked the Plan to pre-approve Skilled nursing facility (SNF) care. You say that requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says The denial of authorization for these 
services is correct. 
 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 Skilled nursing facility (SNF) care. Our 
reviewer says that Based on current evidence based literature, the requested skilled nursing facility admission is 
not medically necessary. Our physician reviewer found Based on the documentation provided, it is my opinion 
that the enrollee does not qualify for SNF coverage.  The enrollee does not have documented skilled nursing 
needs.  The enrollee does not have documented skilled therapy needs.  Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition.  The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care (ex. home, AL, 
LTC). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Skilled nursing facility (SNF) care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Skilled nursing facility (SNF) care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat epidural steroid injection.
You asked the Plan to pre-approve a repeat epidural steroid injection. The Plan denied your request. The Plan says a repeat epidural steroid injection does not meet the Medicare LCD criteria.
The Plan follows Medicare 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 pre-approve a repeat epidural steroid injection. Our reviewer says that a repeat epidural steroid injection is not medically necessary. Our physician reviewer found that the procedure note states that the enrollee's preprocedural pain level was five (5) out of ten (10) and postprocedural pain level was zero (0) out of ten (10). A message documented from the enrollee on March 25, 2022, stated "Unfortunately, the injection only lasted [approximately] 6 weeks." Therefore, the criteria of lasting 3 months was not met and 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 a repeat epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy (29826, 29827) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is being recommended so the enrollee can 
move his shoulder without pain. The Plan denied your request. The Plan says that records do not show the 
enrollee has not consistently tried analgesics, physical therapy or anti-inflammatory agents. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures (including medication and physical therapy.) The enrollee is noted to have 
undergone a cortisone injection on March 4, 2022. That is the only limited documentation of conservative 
treatments. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve shoulder arthroscopy (29826, 29827) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transesophageal echocardiography (93312) and doppler 
echocardiography services (93320, 93325) provided on October 8, 2021. 
 
You asked the Plan to pay for the services. You say that the services were billed appropriately. The Plan denied 
your request. The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
Current Procedural Terminology (CPT) 93312 Echocardiography, transesophageal real-time with image 
documentation (2D) with or without M-mode recordings; including probe placement, image acquistion 
interpretation and report 
 
Current Procedural Terminology (CPT) 93320 Doppler echocardiograpy, pulsed wave and/or continuous wave 
with spectral display (List Separately in addition to codes for ehocardiographic imaging); complete 
 
Current Procedural Terminology (CPT) 93325 Doppler echocardiography color flow velocity mapping (List 
separagtely in addition to codes for echocardiography) 
 
We asked our coder 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 serivces. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found in terms of CPT 93312, the procedure 
report does not support this service as diagnostic; therefore, modifier -59 cannot be verified. CPT 93325 and 
93320 are add-on codes. The primary procedure - CPT 93312 - cannot be verified. Therefore, these add-on 
codes would not be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the serivces have not been met. Therefore, we decided that the Plan does not 
have to pay for transesophageal echocardiography (93312) and doppler echocardiography services (93320, 
93325) provided on October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services rendered on November 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
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. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the pathology services rendered on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prostate health supplements purchased from April 15, 2021, 
to March 22, 2022. 
 
You asked the Plan to pay for the supplements. You say that this should be paid for. The Plan denied your 
request. The Plan says the supplement contains saw palmetto and nettle root, which is not a Pick Your Perks 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
supplements is an OTC item. The plan does have a supplemental benefit for over the counter items, but does 
not cover the specific item at issue in this case, as it is an herbal and botanical supplement. Therefore, we 
decided that the Plan does not have to pay for prostate health supplements purchased from April 15, 2021, to 
March 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The Plan denied your request. The Plan says the request 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 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 non-surgical management of an arm fracture. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on November 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head/brain rendered on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary because you cannot 
keep your balance and cannot afford to fall again. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Enhanced Controller Color Graphical Display with 
Blue Tooth Capability (for use with power wheelchair). 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says this item is primarily for the convenience of the enrollee or caregiver. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical 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. Therefore, we 
decided that the Plan does not have to pre-approve an Enhanced Controller Color Graphical Display with Blue 
Tooth Capability (for use with power wheelchair).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services. 
 
You asked the Plan to pay for the LTACH services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the criteria for admission to the LTACH have not been met. 
 
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 pay for 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 record indicates that the enrollee continues to require acute care services before being able 
to transition to a lower level of care, and the enrollee continues to receive acute care services, and these have 
not been denied. Our doctor also found that the medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. Our doctor also 
found that the elements of the coverage rules are not satisfied. 
 
 
 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 pay for long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroidectomy (60252) and neuroplasty (64716) provided 
on October 18, 2021. 
 
You asked the Plan to pay for the thyroidectomy (60252) and neuroplasty (64716). You say that CPT codes 
60252 and 64716 are not supported by the medical records submitted. The Plan denied your request. The Plan 
says CPT codes 60252 and 64716 are not supported by the medical records submitted. 
 
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 60252 is thyroidectomy, total or subtotal for malignancy; 
with limited neck dissection. The CPT Code Manual definition of code 64716 is neuroplasty and/or 
transposition; cranial nerve (specify). 
  We asked our coder 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 thyroidectomy (60252) and neuroplasty (64716). Our 
reviewer says that the documentation submitted was reviewed and does not meet criteria for coverage. Our 
reviewer found the operative report does not include enough detail to confirm the procedure billed with CPT 
code 60252 was performed. The operative report also does not support the procedure billed with CPT code 
64716 was a separate procedure. Therefore, this would be inclusive to the primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the thyroidectomy (60252) and neuroplasty (64716) have not been met. 
Therefore, we decided that the Plan does not have to pay for the thyroidectomy (60252) and neuroplasty 
(64716) provided on October 18, 2021.