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

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on January 5, 
2022. 
 
You asked the Plan to pay for the PT services as billed. You say that the records support the billed services. 
The Plan denied your request. The Plan says the diagnosis codes reported for this claim are not in accordance 
with the ICD-10 coding rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for diagnosis codes that indicate laterality, the 
bilateral code must be used for conditions that are present on both sides of the body. 
 
In this case, both a left-sided and bilateral diagnosis code were used. As only one of these can be considered correct, we find that the Medicare billing rules have not been met. Therefore, we decided that the Plan does not 
have to pay for the physical therapy (PT) services provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided from September 28, 2021, to 
November 11, 2021. 
 
You asked the Plan to pay for the services provided. You say that you have never been charged for office visits. 
The Plan denied your request. The Plan says remaining balances owed must be billed to Medicaid. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that Medicaid covers your 
cost-sharing for Medicare services.  We looked at the file and the rules. The Plans benefit grid shows that you have a $203 deductible, and a 20% 
coinsurance for physician services. This means that you have been charged the correct amount based on your 
contract with the Plan. However, per your plan contract, medical deductibles and cost shares are covered by 
Medicaid. Therefore, we decided that the Plan does not have to pay for the physician services provided from 
September 28, 2021, to November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided on December 
17, 2020. 
 
You asked the Plan to pay for the drug testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there is no concern noted about the enrollee's misuse/abuse of medications, 
no documentation of the enrollee's risk assessment score or information as to why the enrollee's doctor is 
wanting to test for greater than 22 classes of drugs. The Plan states this type of large panel drug tests are rarely 
needed in an outpatient setting to help guide the enrollee's care. 
 
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 drug testing. Our physician reviewer 
found there is no documentation that the requirements listed in the LCD: Drug Testing (L34645) for Medicare 
coverage have been met in this case. Records do not document that the results of a screening drug test are 
presumptively positive, or results of the screen are negative, and this negative finding is inconsistent with the 
enrollee's medical history or there is no presumptive test available, locally and/or commercially, as may be the 
case for certain synthetic or semi-synthetic opioids. 
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing (CPT code G0483) provided on December 17, 2020.
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 the SNF admission. You say that the requested SNF care is medically 
necessary. The Plan denied your request. The Plan says your benefit maximum was exhausted as of May 5, 
2022, for a total of 100 skilled nursing days. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from January 26, 2022, 
through May 5, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be more stable and improving and should only require short-term 
additional acute care services that can safely be completed at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that you require that are not already available and 
covered at the current facility. Transfer 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone 30MG/ACT solution. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Testosterone pump is a self-administered drug and not covered by the enrollee's 
Part B benefits. 
 
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 Testosterone 30MG/ACT 
solution.  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by her 
internal medicine physician, for myoelectric orthotic restoration, using the MyoPro Motion G device. The Plan 
denied your request. The Plan says this item is considered experimental and investigational. Medical studies 
have not proven this item is helpful for the treatment of the enrollees health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services.. You say that inpatient psychiatric care is 
medically necessary. The Plan denied your request. The Plan says that the guidelines for coverage have not 
been met. The Plan says that the services needed can be provided in a less restrictive level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric services. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on April 30, 2022, with Bipolar Disorder Unspecified 
with Psychosis and Major New Disorder, Most Likely Due to Alzheimer's Disease with Behavioral 
Disturbance. Based upon review the records provided it was 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 noted or 
auditory or visual hallucinations. However, the enrollee continued to show disorganization and required 
medication adjustment. It did 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. This enrollee did 
appear to require inpatient mental health treatment beyond the date in question. It did appear that active 
treatment was taking place beyond the date in question. It did appear that the services were reasonably 
expected to improve the enrollees condition or for the purpose of diagnosis beyond the date in question. It did 
appear that the records were supervised and evaluated by a physician. Based upon review the records provided 
for the admission of this enrollee does meet the criteria for continued acute inpatient mental health treatment 
for the dates in question of May 26, 2022, forward. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services. have been met. Therefore, we decided that the 
Plan has to pre-approve inpatient psychiatric services.  
 
 
 
  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on October 27, 2021, billed 
with code 00142-QS. 
 
You asked the Plan to pay for the anesthesia service as billed. You say that this was billed correctly as no 
additional modifier is allowed. The Plan denied your request. The Plan says this was not billed with an 
appropriate modifier for a CRNA service. 
 
The Plan must follow Medicare rules. Medicare rules say that anesthesia modifiers are required to indicate the 
service rendered. For CRNA services, either modifier -QX or -QZ is required, depending on whether there was 
physician direction. 
 
 We looked at the file and Medicare rules. The services at issue are CRNA anesthesia services. No appropriate 
modifier was used. Based on this information, we decided that Medicare rules for coverage of the anesthesia 
service as billed have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on October 27, 2021, billed with code 00142-QS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need a shower chair because it is very hard 
to stand in the shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a routine cost associated with a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Opdivo.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says its step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Remicade. Our reviewer says that 
criteria for coverage of Remicade have not been met. Our physician reviewer found the record indicates that the 
enrollee has granulomatous uveitis in the setting of sarcoidosis. The record indicates that the requested 
medication is a new start as defined by Medicare rules. The provided records do not indicate that the enrollee 
has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from, the plan's preferred step one alternative.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on November 2, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the claim was denied due to a lack of medical records. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. this claim was denied due to a lack of medical records. After this denial, the 
provider sent in valid medical records. There is no reason for the denial anymore, and the plan has not provided 
any new reasons to continue denying these services. Therefore, we decided that the Plan has to pay for 
anesthesia services provided to the enrollee on November 2, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 you need aggressive rehabilitation prior to going 
home so you can regain your previous level of function. The Plan denied your request. The Plan says IRF is not 
medically necessary and you can safely receive the services you need in another setting such as a skilled 
nursing facility or at home with home health and home physical therapy, or at 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 that while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program, such as 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chest x-ray services provided to the enrollee on October 19, 
2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says since both claims were billed to mobile x-ray the claim billed with the technical 
component should be denied, since both both claims should not be paid for the same provider with same Tax 
ID number. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
We find that CPT 71045 is not supported in this case. The provider is billing the technical component modifier 
on this claim and the professional component on the related claim 820213070171527. This is not appropriate 
for this case. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for chest x-ray services provided to the 
enrollee on October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Laparoscopic conversion to Roux-en-y gastric bypass 
with hiatel hernia repair. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that you do not meet national guidelines and/or standard of care for a 
patient with this clinical presentation. 
 
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 requested services are not considered medically reasonable and necessary in this case. The record indicates 
that you underwent sleeve gastrectomy with hiatal hernia repair in 2019. The record is insufficient to 
demonstrate that the coverage criteria for bariatric surgery are satisfied. The record as provided is insufficient 
to establish that you have either a medical complication from a previous bariatric surgery requiring intervention 
or that you have an additional medical issue separate from obesity that requires operative the requested 
procedure. Our physician reviewer found that your condition does not meet criteria for coverage of these 
services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Laparoscopic conversion to Roux-en-y gastric bypass with hiatel hernia repair.