Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PrimaGen Allograft services. 
 
You asked the Plan to pre-approve PrimaGen Allograft services. You say that the records provided support the 
need for the Allograft services in dispute. The Plan denied your request. The Plan says medical studies have not 
proven that the use of this product during spinal surgery is better than standard allograft products. 
 
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 PrimaGen Allograft services. Our 
reviewer says that PrimaGen Allograft services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found PrimaGen Allograft services are considered experimental in spinal surgery. 
Iliac crest autograft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PrimaGen Allograft services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve PrimaGen Allograft services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. The enrollee has had a decline from his 
baseline level of function and would likely benefit from therapy but does not need the intensity of these 
therapies provided in the acute inpatient rehabilitation 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that you have ongoing acute medical issues and still require 
acute care services. You continue to receive acute care services, and these have not been denied. The medical 
record does not indicate that you require services that you are not currently receiving but that would be 
available at the LTACH facility. 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 pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 13, 2021, 
to September 16, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code A41.9 is not supported by the records provided. Our physician 
reviewer found that the enrollee presented to the facility with the chief complaint of elevated blood sugar 
values and weakness, as well as hematuria. Medical history included atrial fibrillation, chronic kidney failure 
with a baseline of 1.3 mg/dL, senile dementia, and was described as dehydrated. The enrollee was stated to 
have generalized weakness with poor oral intake, and initial laboratory data reflected a glucose of over 300. In 
this case, there was no clinical or laboratory evidence of sepsis. The documentation did not support diagnosis 
code A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 13, 2021, to September 16, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitors 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM sensor. You say that you are currently using 
the requested product. You are testing your blood glucose three times a day and you are not on insulin. The 
Plan denied your request. The Plan says you do not meet criteria for approval of the requested sensor. 
 
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 you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections or 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 Freestyle Libre 14-day CGM sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitors 
(CGM) sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show a radionuclide stress 
test was negative and unchanged compared to one in 2020. Echocardiograms have not shown a need for further 
surgery. The guidelines do not support a need for cardiac catheterization in this setting. The services are 
therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac catheterization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82306, 82728, 82977, 
83036, 83540, 84466, 83550, 84436, 84479 and 84480) provided on March 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. 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. The services are not 
authorized because codes 83036, 82306, 82728, 82977, 83540, and 84466 are not a Medicare benefit for the 
diagnoses listed on the claim and are done for screening purposes. There is no documentation of a diagnosis for 
which this testing may be done on the claim form. We must follow Medicare rules, so the decision is to uphold 
the original denial determination. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 84439, 84466, 84481 and 83550, 84436, 84479, 84480. This PTP edit 
has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82306, 
82728, 82977, 83036, 83540, 84466, 83550, 84436, 84479 and 84480) provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 22, 2021. 
 
You asked the Plan to pay for the lab services. 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, for 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 the lab services provided on June 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that you do not 
have documented skilled nursing or skilled therapy needs. In this case home health services, including 
associated home health aide services are not medically necessary or reasonable. 
 
 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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 20A11 battery and charger for a Drive Scout Mobile 
Scooter. 
 
You asked the Plan to pre-approve a 20A11 battery and charger for a Drive Scout Mobile Scooter. 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. Medicare rules say that to repair means to fix or mend and to put the 
equipment back in good condition after damage or wear. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a 20A11 battery and charger for a Drive Scout Mobile Scooter have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a 20A11 battery and charger for a Drive Scout Mobile 
Scooter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33508 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 33508. The Plan denied your request. The Plan says payment for 
code 33508 is bundled into payment for code 33533.  
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 33508 
is a column II code to column I code 33533. 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 33508 billed for date of service February 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) at three levels (64493, 
64494, 64495). 
 
You asked the Plan to pre-approve a MBB at a third level. You say that You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says a MBB at a third level is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 MBB at a third level. Our reviewer 
says that a MBB at a third level is not medically necessary. Our physician reviewer found MBBs at one to two 
levels, either unilateral or bilateral, are allowed per session per spine. Therefore, the reviewer found that a 
MBB at a third level is 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 MBB at a third level have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks (MBBs) at three levels (64493, 64494, 64495).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement of prosthesis (L5321, L5624, L5631, 
L5649, L5650, L5651, L5652, L5679, L5828, L5845, L5848, L5850, L5856, L5920, L5925, L5950, L5968, 
L5981, L8430, L8460, L8480). 
 
You asked the Plan to pre-approve a replacement of prosthesis. You say that the enrollee has an increase in 
activity level and has fallen due to his current socket not fitting well and his current knee and foot not being 
able to handle the activities that he is now capable of doing. The Plan denied your request. The Plan says the 
request for replacement prosthesis with advanced components does not meet Medicare criteria as reasonable 
and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve replacement of prosthesis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the 
replacement prosthesis with advanced components at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. Provided records do not document that the enrollee's present 
prosthesis has been lost, stolen or irreparably damaged or has reached its reasonable useful lifespan or that 
there has been a significant change in the enrollee's physiological condition to meet criteria for a replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of replacement of prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a replacement of prosthesis (L5321, L5624, L5631, L5649, L5650, L5651, 
L5652, L5679, L5828, L5845, L5848, L5850, L5856, L5920, L5925, L5950, L5968, L5981, L8430, L8460, 
L8480).
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and is currently unstable for transfer to an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 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 Plan. The Plan has approved ongoing care in the current 
acute care setting. 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 6, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20553 and 76942 billed for date of service 
July 6, 2022. 
 
You asked the Plan to pay for procedure codes 20553 and 76942. The Plan denied your request. The Plan says 
payment for codes 20553 and 76942 is bundled into payment for code 20611.  
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 codes 
20553 and 76942 are column II codes to column I code 20611. 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 codes 20553 and 76942 billed for 
date of service July 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colesevelam tablet 
 
You asked the Plan to pre-approve colesevelam. You say that the enrollee has not had success with other 
medications to treat their condition. The Plan denied your request. The Plan says the requested drug is 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 colesevelam tablet  
 Benefits for colesevelam may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.