Persius/hicric huggingface dataset:
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 clinical documentation shows that you have complex functional impairments 
however there are no active medical comorbidities specified. The team lists comorbidities and the primary team lists medical conditions as stable. Thus, you would not be expected to require close medical supervision on an 
inpatient basis in the IRF 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 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 definitive drug testing (G0483) provided on April 25, 2022. 
 
You asked the Plan to pay for definitive drug testing. You say that this test was medically necessary and was 
ordered by the enrollee's physician. The Plan denied your request. The Plan says the criteria for medical 
necessity of this test are not met in this case. 
 The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is indicated when the 
results of the screen are presumptively positive, when the results of the screen are negative, but this negative 
finding is inconsistent with the enrollees medical history, or when the criteria are met and there is no 
presumptive test available.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of definitive drug testing have not been met. Specifically, the medical record provided does not show 
screening test results which are positive or inconsistent with the enrollees prescription medications, dosing 
schedules or history. There is also no indication in the file that there was no presumptive test to this enrollee. 
Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0483) provided on April 
25, 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 the enrollee was admitted for respiratory failure and COPD exacerbation. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 the 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: 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 the review indicates that the enrollee does not require services at the LTACH that are 
not available at the acute care hospital where he/she is currently receiving care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that this equipment is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this equipment is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that there is sufficient science published in 
peer-reviewed publications. You say that the requested procedure improves the quality of life of patients 
suffering from vertebrogenic low back pain. You say that the Food and Drug Administration's (FDA's) 
clearance of this device means that the procedure is safe and effective. The Plan denied your request. The Plan 
says there is little evidence in the medical literature to suggest that this is an appropriate procedure for the 
enrollee's back pain. The Plan says that it is not an accepted standard of medical practice for the diagnosis or 
treatment of back pain. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 this is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 all medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
offered by the Plan. 
 
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 Pembrolizumab. 
 
You asked the Plan to pre-approve Pembrolizumab. You say that a novel combinatorial treatment approach is 
medically necessary for the enrollee as prescribed. The Plan denied your request. The Plan says the approach 
and requested regimen remain experimental/investigational for metastatic pancreatic adenocarcinoma. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pembrolizumab. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found Pembrolizumab is not approved by 
the Food and Drug Administration (FDA) for the enrollee's diagnosis. The use of this drug is not supported by 
one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
The enrollee initially underwent curative treatment with neoadjuvant chemotherapy, chemoradiation, followed 
by surgical resection. Metastatic recurrence was noted in February of 2022. The enrollee was referred to the 
Rare Cancer and Precision Medicine Clinic. Based on genomic vulnerabilities, a request was made for Pembrolizumab used in combination with Trametinib and Palbociclib. This proposed treatment regimen is not 
supported by National Comprehensive Cancer Network (NCCN) recommendations. There is insufficient 
support in the medical literature for the proposed regimen for the treatment of recurrent metastatic pancreatic 
cancer. While Pembrolizumab is indicated for the treatment of patients with unresectable or metastatic, 
microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) solid tumors, as determined by an 
FDA-approved test, that have progressed following prior treatment and who have no satisfactory alternative 
treatment options, this is not applicable to this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pembrolizumab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abiraterone acetate. 
 
You asked the Plan to pre-approve Abiraterone acetate. 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 Abiraterone acetate.  
 
Benefits for Abiraterone acetate 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 a folding wheeled walker (E0143) and seat attachment 
(E0156). 
 
You asked the Plan to pre-approve a folding wheeled walker and seat attachment. You say that your medical 
condition and fall risk warrants a rollator type walker and is supported by your physical therapist. The Plan 
denied your request. The Plan says you have received this DME within the past 5 years. 
 The Plan must follow Medicare rules. Medicare rules say DME is provided every five (5) years for new 
equipment.  
 
We looked at the file and Medicare rules. The records show that you were approved for a rollator walker with 
seat in December 2020. Medicare rules confirm the plan covers DME every 5 years for new equipment. Based 
on this information, we decided that Medicare rules for coverage of a folding wheeled walker and seat 
attachment have not been met. Therefore, we decided that the Plan does not have to pre-approve a folding 
wheeled walker (E0143) and seat attachment (E0156).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92604 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 92604. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid. 
 
In this case, the MUE for CPT code 92604 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of procedure code 92604 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 92604 billed for date of service 
July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 9, 2022 billed with 
codes 81226, 81227, & 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says multiple unbundled codes were billed for a single panel. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 9, 2022 billed with codes 81226, 81227, & 81225.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment (A4604, A7030, A7031, A7035, A7038, 
A7039, E0562, E0601) provided on April 28, 2022. 
 
You asked the Plan to pay for the medical equipment. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The records do not include an itemized shipping invoice. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for medical equipment (A4604, A7030, A7031, 
A7035, A7038, A7039, E0562, E0601) provided on April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74178-TC billed for date of service 
September 2, 2021. 
 
You asked the Plan to pay for procedure code 74178-TC. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this service is not supported 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. 
 
We asked our coder 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 procedure code 74178-TC. Our reviewer says that this 
service is not supported as billed in this case. Our reviewer found the medical records support that procedure 
code 74178 was performed; however, the breakdown of the record is only for the professional services which 
would be reported with modifier 26. However, in accordance with some payer guidelines, modifier 26 or TC 
should not be appended to a radiology code when reporting a global service in which one provider renders both 
the professional and technical components. Per the explanation of benefits and the claim form, this was a facility bill. The documentation shows only the professional component. Additional information for the facility 
side is necessary to support this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 74178-TC have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 74178-TC billed for date of service September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics/inserts (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has had problems in her ankles 
particularly the right ankle for approximately 20 years. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics/inserts (L3020).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0429-RW) provided on April 20, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were provided and reported in 
accordance with Medicare rules and should be paid. The Plan denied your request. The Plan says that the 
destination modifier used on this claim is invalid. 
 
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 A0429-RW is supported in the medical record. Specifically, modifier "W" is an 
appropriate destination modifier for use with ET3 ambulance claims. Based on this information, we decided 
that Medicare rules for coverage of ambulance services have been met. Therefore, we decided that the Plan has 
to pay for ambulance services (A0429-RW) provided on April 20, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (86077) provided on May 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment is not allowed for this service 
because the manifestation diagnosis code cannot be billed in the primary position. 
 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 looked at the file and Medicare rules. In this case, this code was billed with a primary/first-listed diagnosis 
code D63.0 (anemia in neoplastic disease). Certain conditions have both an underlying etiology and multiple 
body system manifestations due to the underlying etiology. For such conditions, it is required that the 
underlying condition be sequenced first followed by the manifestation. That means the primary/first-listed 
diagnosis code is incorrect for this billed code. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services (86077) provided on May 18, 2022.