Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura. 
 
You asked the Plan to pre-approve Opzelura. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Opzelura.  
 
Benefits for Opzelura 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: 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 SNF care. You say that you would like a short SNF stay to transition the 
enrollee since she has recently made strides in therapy. The Plan denied your request. The Plan says based on 
Medicare guidelines, the SNF services being requested do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental for use as bone graft material in spine 
surgery. More research is needed. Iliac crest bone graft 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
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 HBOT is covered for specific indications only. 
 
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 criteria for coverage are not met. Our physician reviewer found the enrollee has a Wagner three diabetic 
right foot ulcer following a great-toe amputation. Treatments and assessments since December 14, 2022 have 
shown overall reduction in the size of the ulcer. The area of the wound was 12 centimeters squared (cm2) on 
this date. At the time of the HBOT asessment on January 4, 2023 the area was six cm2. Since there has been 
progress in healing over the past 30 days, the HBOT is not indicated. 
 
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 hyperbaric oxygen therapy (HBOT).
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. The Plan denied your request. The Plan says there is 
no documentation that the enrollee will benefit from and improve with LTACH management and does not 
require extensive or complex wound care management by skilled nursing of at least 6.5 hours per day. 
 
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 at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (75736, 75774) provided July 1, 2022.

You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The
Plan denied your request. The Plan says the codes billed 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, the CPT Code Manual definitions of codes 75736, & 75774 are radiological supervision and
interpretation of selective or supraselective pelvic angiograph, and a selective angiography, for each additional
vessel studied after basic examination, radiological supervision and interpretation.

We find that CPT codes 75736, & 75774 are not supported in the medical record. Specifically, these radiology
procedures are inclusive to the base surgical procedure, code 37244. Based on this information, we decided that
Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan
does not have to pay for radiology services (75736, 75774) provided July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom Receiver, Transmitter, and Sensors. 
 
You asked the Plan to pre-approve a Dexcom Receiver, Transmitter, and Sensors. You say that the enrollee 
would greatly benefit from the requested system. You say that the requested CGM therapy will allow you to 
assist the enrollee with managing her diabetes care. You say that not allowing coverage for the requested CGM 
therapy can lead to several systemic complications in the future. You say that the enrollee was provided with a 
CGM sample and it proved to be a great benefit to her care. The Plan denied your request. The Plan says the 
criteria for coverage have 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom Receiver, Transmitter, and Sensors have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom Receiver, Transmitter, and Sensors.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the respiratory therapy services provided by a physical therapist (PT) 
on August 15, 2022. 
 
You asked the Plan to pay for the respiratory therapy. You say that this was billed correctly. The Plan denied 
your request. The Plan says that services billed with modifier -GP can only be reported under revenue code 
042X. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory therapy provided by a PT should be 
billed with a 97XXX code with the -GP modifier. These services provided in a CORF must be reported under 
revenue codes 0410, 0412, and 0419. 
 
We looked at the file and Medicare rules. The records show this service was provided by a PT in a CORF. It 
was correctly billed with code 97110-GP under revenue code 0410. Based on this information, we decided that 
Medicare rules for coverage of the respiratory therapy have been met. Therefore, we decided that the Plan has 
to pay for the respiratory therapy services provided by a physical therapist (PT) on August 15, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have 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 does not show that the enrollee is using insulin. 
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 Sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee has a procedure currently approved as an 
ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require 
a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 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 acute inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission is 
met in this case. Our physician reviewer found the enrollee has shoulder pain and osteoarthritis that is 
refractory to conservative management. She is undergoing a planned reverse total shoulder arthroplasty. The 
enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The 
planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is 
currently approved as an ambulatory procedure. There is no documentation provided to support the expectation 
the enrollee will require a greater than 2 midnight stay. The review has determined that the record does not 
show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve acute inpatient hospital admission.
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 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract between 
the dialysis facility and the laboratory regarding payment. 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 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tracheostomy, inner cannula (CPT code A4623), gauze 
(A6402) and filter holder and integrated filter without adhesive (A7507) provided on May 23, 2022. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code A7507 (62 Units) remains not supported. The submitted medical records do not include a patient 
receipt or proof of delivery of the billed supply, on the billed date of service. This means the billed code and 
units cannot be verified. CPT code A6402 (200 Units) remains not supported. The submitted medical records 
do not include a patient receipt or proof of delivery of the billed supply, on the billed date of service. This 
means the billed code and units cannot be verified. CPT code A4623 (62 Units) remains not supported. The submitted medical records do not include a patient 
receipt or proof of delivery of the billed supply on the billed date of service. This means the billed code and 
units cannot be verified. Based on this information, we decided that Medicare rules for coverage of the DME 
have not been met. Therefore, we decided that the Plan does not have to pay for tracheostomy, inner cannula 
(CPT code A4623), gauze (A6402) and filter holder and integrated filter without adhesive (A7507) provided on 
May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drugs coded J3490 provided on June 8, 
2022. 
 
You asked the Plan to pay for the unclassified drugs. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed 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, the CPT Code Manual definition of code J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as a surgery procedure. This means this service is included in the global surgical 
procedure and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the unclassified drugs have not been met. Therefore, we decided that the Plan does not have to pay 
for the unclassified drugs coded J3490 provided on June 8, 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610 billed for date of service May 2, 2022. 
  You asked the Plan to pay for procedure code 20610. You say that the claim should be processed as soon as 
possible. The Plan denied your request. The Plan says payment for code 20610 is bundled into payment for 
code 27096. 
 
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 20610 
is a column II code to column I code 27096. 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 20610 billed for date of service May 2, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 you were admitted for lithium toxicity and a urinary tract infection. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. 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. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 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 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 2 Sensor.