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

 
We decided that the Plan does not have to pay for lab services provided on May 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 26, 2021.
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 LTACH care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to 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 patient is an 83-year-old female with chronic respiratory insufficiency 
requiring home oxygen who was admitted to the acute care hospital with pneumonia and atrial fibrillation 
treated with antibiotics and oxygen. The course was complicated by worsening mental status, diagnosis of 
cerebral vascular accident, and requiring mechanical ventilation support. Tracheostomy (TRACH) and 
percutaneous endoscopic gastrostomy (PEG). Recent notes describe the patient as having failed weaning 
attempts, however, encephalopathy not improving with treatment. Palliative care was consulted. The patient 
appears to not be improving further and is unable to wean and should only require short-term additional acute care services that can safely be administered at the current facility until more appropriate for a lower level of 
care. The patient does not require services at the LTACH that are not already available at the current facility. 
There are no services at the LTACH that the patient requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
Transfer to a lower level of care may be considered when treatment has completed. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology (88305) provided on September 15, 
2021. 
 
You asked the Plan to pay for the surgical pathology (88305). You say that the claim denied in error because 
this submission doesn't represent a duplicate procedure but analysis of a separate biopsy specimen. You say 
that this is standard of care and the claim should be reprocessed. The Plan denied your request. The Plan says 
the denial is upheld as the billed procedure code 88305 has a Physician Fee Schedule indicator of 1. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the records indicate that the 
member was an outpatient on the billed date of service. Payment for CPT code 88305 is included in the 
payment to the facility and is the responsibility of the facility to any vendor. Based on this information, we 
decided that Medicare rules for coverage of the surgical pathology (88305) have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical pathology (88305) provided on September 15, 2021.
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 states you can 
safely receive the services you need in other settings, for example: a skilled nursing facility, home with home 
health services, or home with outpatient therapy. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for tremors after recent COVID-19 pneumonia. 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 you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allograft for spine surgery (20930) provided, on June 18, 
2021. 
 
You asked the Plan to pay for the allograft for spine surgery (20930). You say that medical notes should be 
reviewed for payment. The Plan denied your request. The Plan says bundled services are not eligible for 
separate payment. 
 
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 20930 is allograft, morselized, or placement of 
osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure). 
 
  We find that CPT code 20930 is not supported in the medical record. Specifically, CPT code 20930 has a status 
indicator of B. This means that CPT code 20930 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the allograft for spine surgery (20930) have 
not been met. Therefore, we decided that the Plan does not have to pay for the allograft for spine surgery 
(20930) provided, on June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found these devices are experimental, More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
is no longer an imminent danger to self or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient services from March 24, 2022, forward were requested. 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 continued services. Our physician reviewer found that it was not expected 
this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal 
or homicidal ideation, auditory or visual hallucinations.  She was compliant with treatment while not showing any acute threats to safety. It does not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) 
physical therapy provider. 
 
You asked the Plan to pre-approve OON services. You say that unlocking your hip will stop the pain. The Plan 
denied your request. The Plan says there are multiple in-network providers that can provide this service. 
 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve services 
to be provided by an out-of-network (OON) physical therapy provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor for the enrollee. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says that the enrollee is not receiving insulin shots or using an insulin 
pump. 
 
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 
Freestyle Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (CGM) sensor for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulsed radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve pulsed RFA services. You say that this procedure is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this procedure is not covered according to 
Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say there is insufficient evidence in the published medical 
literature to determine the safety and efficacy of pulsed RFA services. Based on this information, we decided 
that Medicare rules for coverage of pulsed RFA services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pulsed radiofrequency ablation (RFA) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve a group 3 power wheelchair. You say that the enrollee lives in an assisted 
living/retirement community. You say that the enrollee has dementia, multiple sclerosis, failure to thrive, and 
gait instability. You say that the enrollee is unable to propel himself in a manual wheelchair. The Plan denied 
your request. The Plan says the medical records sent do not say that there was a home and specialty evaluation 
performed by a licensed/certified medical professional who has specific training and experience in 
rehabilitation wheelchair evaluations. 
 The Plan follows Medicare rules. Medicare rules say that there must be a written report of an on-site evaluation 
of where the enrollee lives and that there must be a written report of this evaluation upon request. 
 
The file shows that the Plan requested a written report of an on-site evaluation of where the enrollee lives. 
There is no evidence that this on-site evaluation was done or that a written report was provided. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits (99213) to be provided by a 
licensed mental health counselor. 
 
You asked the Plan to pay for the office visits. You say that you feel this should be covered because you have 
had a relationship with this counselor for over a year and a half and it would be detrimental to start all over 
again with a new counselor. The Plan denied your request. The Plan says the provider is a licensed mental 
health counselor and is not Medicare certified providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient office visits (99213) to be 
provided by a licensed mental health counselor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 April 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee is a 72-year-old female with a 
past medical history of seizures, hypertension and ovarian cancer who presented to the acute hospital on March 
6, 2022, after being found down in her bathroom after an apparent fall; she had a seizure in the emergency 
room and was admitted. In this case, skilled nursing services are not required. While the enrollee does require 
skilled therapy services, these services are not required on a daily basis. The patient is walking household 
distances with a rolling walker with contact guard assistance and is close supervision level for transfers. Based 
on the medical records provided there is no documentation that the patient requires the services on an inpatient 
basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term 
care facility on a part time basis appear appropriate in this case. 
 
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 admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
experimental/investigational. 
 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Durvalumab (J9173) with supporting 
medications Lorazepam (J2060), Dexamethasone Sodium Phosphate (J1100) Ondansetron Hydrochloride 
(J2405), Diphendhydramine HCL (J1200), and Famotidine (J3490). 
 
You asked the Plan to pre-approve treatment with Durvalumab and supporting medications. You say that this is 
medically necessary. The Plan denied your request. The Plan says there is not recent imaging to support this 
request. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 treatment with Durvalumab and 
supporting medications. Our reviewer says that the requested drug treatment is not supported in the records. 
Our physician reviewer found updated imaging documenting disease stability following your completion of 
therapy is needed to show the requested drugs are medically necessary and appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment with Durvalumab and supporting medications have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Durvalumab (J9173) with 
supporting medications Lorazepam (J2060), Dexamethasone Sodium Phosphate (J1100) Ondansetron 
Hydrochloride (J2405), Diphendhydramine HCL (J1200), and Famotidine (J3490).