Persius/hicric huggingface dataset:
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 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. 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 available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 84480 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 84480 (triiodothyronine [T3] assay) and 84481 (free assay 
[FT-3]). Code 84480 is a column II code with a modifier indicator of 1 when billed with column I code 84481. 
Code 84480 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs or skilled therapy needs. The enrollee appears to have reached a plateau in 
function.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration 
of the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that you would like Xiidra to be approved to help the 
enrollee's corneal surface dryness. The Plan denied your request. The Plan says Xiidra is a self-administered 
drug. 
 
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 Xiidra.  
 
Benefits for Xiidra 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on February 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified.  
 
We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the special anesthesia service rendered on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease testing (87798, U0005, U0004) 
provided August 20, 2021. 
 
You asked the Plan to pay for the infectious disease testing. You say that due to the critical clinical value of the 
testing that benefits the enrollee, you ask for reconsideration for denial and request payment in full for the 
testing. The Plan denied your request. The Plan says the documentation does not support that the services 
rendered were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the infectious disease testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the request does not meet Medicare rules, as the panel performed had more than 
5 pathogens on it. While testing for the bacterial pathogens may have clinical utility in specific patient 
populations, the pathogens are included in the single test (Full Respiratory Panel), which does not meet 
Medicare reasonable and necessary requirements. The review has determined that the items/services at issue in 
this case were not medically reasonable and 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 the infectious disease testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the infectious disease testing (87798, U0005, U0004) provided August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the meningococcal B vaccine rendered on August 4, 2021. 
 
You asked the Plan to pay for these services. You say that your doctor recommended you get the vaccine. The 
Plan denied your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the meningococcal B vaccine rendered on August 
4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 3, 2021.
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 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. 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee has 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 enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 83789 is not supported. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, a complete description of the 
code was not documented and the file shows that the urine specimen was collected for drug testing. 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 pay for the laboratory services rendered on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 28, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was medically necessary and billed correctly. The Plan denied your request. The Plan says the POS 
code billed on this claim is incorrect. 
 
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 Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that specimens are collected to perform 
diagnostic tests independent of a physician's office. The Plan denied your request. The Plan says one CPT code 
must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a genetic testing panel was provided. The panel was billed with multiple codes. We looked 
at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service 
may be reported for the procedure. 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 the lab testing 
services provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the amniotic fluid injection (CPT code Q4215 x 160 
units). 
 
You asked the Plan to pre-approve the amniotic fluid injection. You say that you are requesting amniotic fluid 
injection into the enrollee's lumbar spine to help with their chronic pain. The Plan denied your request. The 
Plan says there are not enough studies to show the amniotic fluid injection improves the health of patients with 
the enrollee's medical condition, there are not enough studies to show the amniotic fluid injection will help in 
the enrollee's care, and there are not enough studies to show the amniotic fluid injection is better than regular 
treatment for the enrollee's problem. 
 
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 amniotic fluid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found amniotic fluid injection in the spine 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 amniotic fluid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the amniotic fluid injection (CPT code Q4215 
x 160 units).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve denosumab. 
 
You asked the Plan to pre-approve denosumab. You say that this is medically necessary. The Plan denied your 
request. The Plan says that that documentation must show that you are not having any major problems with the 
denosumab treatments you have had so far. 
 
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 denosumab. Our reviewer says that 
denosumab is medically reasonable and necessary. The record indicates that you have a diagnosis of 
osteoporosis. The record indicates that you were last seen by the provider in February 2022 and continue to 
have a diagnosis of osteoporosis. The request is for continuation of therapy. The Food and Drug Administration 
has stated that the requested drug is indicated for your condition. Our physician reviewer found that your 
condition meets criteria for coverage of denosumab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of denosumab have been met. Therefore, we decided that the Plan has to pre-
approve denosumab.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexletol. 
 
You asked the Plan to pre-approve Nexletol. You say that it is recommended that the enrollee start taking 
Nexletol to adequately control her lipids, given her intolerance to statin agents. The Plan denied your request. 
The Plan says Nexletol falls under part D 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 Nexletol.  
 
Benefits for Nexletol 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on July 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on July 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation service provided on November 10, 2021. 
 
You asked the Plan to pay for the transportation service. You say that the company that transported you was a 
backup because the ambulance company was busy. You also say that you did not ask for additional paramedic 
services, just the ambulance itself. The Plan denied your request. The Plan says paramedic intercept services 
are not a covered benefit if not rendered in a rural area. The Plan also says that the locations you were picked 
up from and transported to are both urban areas and are not covered. 
 
 
  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
transportation service provided on November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
 
 
 
 We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (CPT code 99233) provided on July 
26, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 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 99233 
is a column II code to column I code 90847. 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 subsequent hospital care (CPT code 99233) provided on July 26, 
2021.