Persius/hicric huggingface dataset:
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 enrollee meets all LTACH admission 
criteria and in order to sustain a safe and sustainable discharge, LTACH is the best option to reach the ultimate 
goal of returning home. The Plan denied your request. The Plan says the request for admission to an LTACH is 
being denied as 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 the enrollee appears to be approaching their baseline and is improving and should 
only require short-term additional acute care services that can safely be provided at the current facility. 
Transfer to the LTACH would not be clinically advantageous at this time and completion of treatment at the 
current facility 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75820 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 75820. The Plan denied your request. The Plan says payment for 
code 75820 is bundled into payment for code 37187.  
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 75820 
is a column II code to column I code 37187. 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 75820 billed for date of service April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve a vacuum pump. You say that medical justification is attached for the 
vacuum-assisted socket system. The enrollee has not received his prothesis. The Plan denied your request. The 
Plan says experimental items and items that are not shown to be safe and effective cannot be covered. 
Therefore, the requested vacuum socket cannot be covered. 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 vacuum pump. 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 vacuum-assisted 
socket system at issue in this case meets all Medicare criteria for medically reasonable and necessary for the 
enrollee. Provided medical records from the enrollee's treating physician document a loose socket but do not 
document necessity of the vacuum-assisted socket system for this enrollee's condition and prosthesis. 
 
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 vacuum pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume management 
and moisture evacuation system (L5781).
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 June 22, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
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 June 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immunotherapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve immunotherapy. You say that you were under the impression that the plan 
offered OON benefits. You were also told that if you switched from an HMO plan to a PPO plan, your out-of-
pocket maximum would be different. You are very upset and confused with this denial. The Plan denied your 
request. The Plan says you do not have out of network benefits with the exception of urgent/emergent care. The 
Plan has participating providers available in network who can 
render immunotherapy. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
immunotherapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service April 6, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that these services were 
billed correctly and should be paid. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable as billed.  These codes needed to be billed with the 26 modifier.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service April 6, 2022.
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 enrollee is a great candidate for acute rehab, can 
tolerate three hours of therapy a day and will return home with family support. The Plan denied your request. 
The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (99183, G0277). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the enrollee had bilateral 
amputation done in August 2022. The wounds on his legs are so bad that you can see the bones which means 
there is a huge chance of infection. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria set by the NCD 20.29.  
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee has diabetes type 1 and underwent bilateral below knee 
amputations in August 2022. The enrollee now has advanced breakdown of both stump wounds, with exposed, 
infected bone and muscle. According to the infectious disease consultant, who saw the enrollee on December 1, 
2022, there is no reasonable possibility of healing these wounds by any means, including Hyperbaric oxygen 
therapy. The recommendation was for bilateral above knee amputation. Hyperbaric oxygen therapy would 
therefore be futile. Hyperbaric oxygen therapy is considered not 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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy (99183, G0277).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed with codes 17000 and 17003 for June 22, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these 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 17000 
is a column II code to column I code 11102. This claim has not been billed with an appropriate modifier to 
bypass the edit. We have also confirmed that code 17003 is an add-on code, and as the primary procedure code 
17000 is not payable, the add-on code is also not payable. 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 services billed with 
codes 17000 and 17003 for June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on June 15, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the items billed are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The billed supply code is not supported in the documentation submitted. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies provided on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have submitted medical records to support 
payment. 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 lab services provided on September 23, 2022.
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in 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 is currently receiving appropriate services in the acute care setting. 
Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower 
level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 
facility. The Plan has not stated that continued care in the short-term acute hospital will not be covered. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic comprehensive preventive medicine 
reevaluation and management of an individual including an age and gender appropriate history, examination 
(99397). 
 
You asked the Plan to pre-approve a preventive medicine visit with a gynecologist. You say that the enrollee is 
due for a bone density screening and needs to be seen to get an order for her exam. The enrollee also needs to 
discuss the medication for treatment of her on-going condition of oral HSV. The Plan denied your request. The 
Plan says while the requested service may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a preventive medicine visit with a gynecologist have not been met. Specifically, the Plan has 
approved a screening pap smear and pelvic and clinical breast exam with this provider. Therefore, we decided 
that the Plan does not have to pre-approve a periodic comprehensive preventive medicine reevaluation and 
management of an individual including an age and gender appropriate history, examination (99397).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
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. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on September 2, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. 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 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 use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for chiropractic services provided by an out-of-
network provider from March 19, 2022, to April 23, 2022. 
 
You asked the Plan to pay the full cost for chiropractic services. You say that you have not been reimbursed the 
correct amount for these services. The Plan denied your request. The Plan says these services processed 
correctly. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan offers coverage of routine chiropractic 
services, but the services must be provided by a network chiropractor. 
 
We looked at the file and Medicare rules. The record does not show that you had a subluxation when these 
services were provided. While the Plan provides coverage for routine chiropractic services, you are required to 
use a network provider. Although the Plan has provided partial coverage for these services, these services were 
provided by an out-of-network provider and therefore are not covered under your contract. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. 
Therefore, we decided that the Plan does not have to pay the full cost for chiropractic services provided by an 
out-of-network provider from March 19, 2022, to April 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional physical therapy visits. 
 
You asked the Plan to pay for physical therapy. You say that you believe without continued physical therapy 
not only would you have adhesive capsulitis but potentially a need for further intervention. You say that you 
can also have permanent diminished range of motion. The Plan denied your request. The Plan says additional 
physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 pay for physical therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. You have no recent injury or a decline in function. The 
additional therapy services are not appropriate duration and frequency for treatment of your medical condition 
and therefore are not 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for additional physical therapy visits.