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 health plans denial should be upheld. You do not require the intensity of services 
provided at an IRF. Specifically, you are not shown to require fifteen (15) hours per week of rehabilitative 
services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy rendered on January 26, 2022. 
 
You asked the Plan to pay for these services. You say that you were told the services were part of the Plan 
coverage. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for the massage therapy rendered on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 83631, 82656, 83520, 
82274, 87798, 82705, 89055, 87177 and 87209 provided November 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached documents and 
process the claim accordingly. The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
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. The submitted medical 
documentation indicates that the specimen was obtained in an office setting POS 11. Of note, the enrollee 
resides in Florida and the billing laboratory is located in New Jersey. The Plan made multiple attempts to 
obtain additional information form the provider. Therefore, we decided that the Plan does not have to pay for 
the laboratory services coded as 83631, 82656, 83520, 82274, 87798, 82705, 89055, 87177 and 87209 
provided November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal injection. 
 
You asked the Plan to pre-approve a spinal injection. 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 follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary when specific criteria are met. 
 
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 spinal injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
indicating that the diagnostic facet joint injections provided a consistent minimum of 80% sustained relief of 
primary (index) pain (with the duration of relief being consistent with the agent used). The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 spinal injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a spinal injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) leads 
rendered on November 7, 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 modifier -NU must be billed for durable medical 
equipment that is new.  
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -NU 
modifier. 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 transcutaneous electrical nerve 
stimulation (TENS) leads rendered on November 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Brand Specific Drive Bed Wedge with a 12" rise 
#RTL3827, (a bed cushion that lifts and supports your neck, to help relieve pain and breathing problems, for a 
person lying down in bed) (E1399). 
 
You asked the Plan to pre-approve a bed wedge. You say that you have trouble getting out of bed. Medical 
records were provided for coverage reconsideration. The Plan denied your request. The Plan says the requested 
item is not covered by Medicare or your Plan. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bed wedge. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found durable medical equipment is defined as equipment which can withstand repeated use (could 
normally be rented and used by successive enrollees), is primarily and customarily used to serve a medical 
purpose, is generally not useful to a person in the absence of an illness or injury and is appropriate for use in an 
enrollees home. In this case, the requested item would not be considered DME. Additionally, there must be an 
appropriate duration and frequency that is considered appropriate for this service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bed wedge have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Brand Specific Drive Bed Wedge with a 12" rise #RTL3827, (a bed cushion that lifts 
and supports your neck, to help relieve pain and breathing problems, for a person lying down in bed) (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (with lateral transverse technique, when performed) (22612) and an insert spine fixation 
device (22840). 
 
You asked the Plan to pre-approve outpatient arthrodesis surgery. You say that the requested surgery is 
medically necessary. The Plan denied your request. The Plan says the requested surgery does not meet criteria. 
 
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 outpatient arthrodesis surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has spinal stenosis with neurogenic claudication. She takes 
several medications for pain. She has had PT, MBB and Lumbar Epidural Steroid Injections. This procedure 
would be experimental/ investigational. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient arthrodesis surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar 
(with lateral transverse technique, when performed) (22612) and an insert spine fixation device (22840).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on April 27, 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 injection services rendered on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and this 
claim should be paid. The Plan denied your request. The Plan says you billed an incorrect place of service on 
the claim. 
 
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 lab 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 lab services provided on May 14, 2021.
Appeal type: Drugs
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. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections are only covered for 
certain indications. 
 
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 the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has not had 
physical therapy. On April 6, 2022 the enrollee had a transforaminal epidural steroid injection with minimal 
relief. The documentation does not support that the enrollee had at least 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline using the same scale for at least three months. Therefore, the enrollee does not meet criteria for the requested 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 26, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service February 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and this 
claim should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
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 lab 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 lab services provided on March 17, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the advanced life support (ALS) ambulance services provided on 
August 2, 2021, billed with code A0427. 
 
You asked the Plan to pay for the ALS services coded A0427. You say that the reduction of payment to basic 
life support is not appropriate. Payment of code A0427 should be made. The Plan denied your request. The 
Plan says that the diagnosis code does not support payment of ALS. As such, payment was made for code 
A0429 only. 
 
The Plan follows Medicare rules. Medicare rules say that payment for ALS services is appropriate when the 
provision of an ALS assessment or at least one ALS intervention is required.  
 
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 ALS services coded A0427. Our 
reviewer says that the documentation supports that the criteria for coverage of ALS services are met. Our 
physician reviewer found the patient was diagnosed with sepsis, acute renal failure, and hyperkalemia and was 
hypotensive during transportation. Medically necessary services included the provision of an ALS assessment 
required to be done by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-
Paramedic.  
 
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 ALS services coded A0427 have been met. Therefore, we decided that the 
Plan has to pay for the advanced life support (ALS) ambulance services provided on August 2, 2021, billed 
with code A0427.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Bevacizumab injection provided on October 28, 2021. 
 
You asked the Plan to pay for the Bevacizumab injection. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that this procedure is included in the primary 
procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan is denying this procedure stating that this 
procedure is included in the primary procedure. However, the documentation does not include explanation of 
what codes this procedure is included in. In addition, there is a pre-approval letter in the documentation stating 
that this service was being pre-approved for dates of service August 5, 2021 to February 5, 2022. The 
documentation does not include an accurate explanation of why this service is no longer being covered. The 
Plans decision to deny this service is not substantiated by the documentation. Therefore, we decided that the 
Plan has to pay for the Bevacizumab injection provided on October 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 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 September 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mesalamine for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Mesalamine for the 
enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that Ilumya is the appropriate treatment for the enrollee. 
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the 
Plan requires a trial of Remicade or Avsola before it will approve Ilumya. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Ilumya. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Remicade or Avsola. The record does 
not show that these drugs would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Ilumya.