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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have 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 that you were admitted for surgical repair of a femur fracture after a fall. 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. In conclusion, there is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the peripheral nerve stimulation 
(PENS) device. 
 
You asked the Plan to pre-approve the PENS device. You say that the PENS device is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the current peer-reviewed data does not 
support this procedure for fibromyalgia, phantom limb pain, diffuse polyneuropathy, nociceptive pain in trunk 
or lower back, or angina pectoris. 
 
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 PENS device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental/ investigational for knee pain. Therefore, the request is considered not medically reasonable or 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 PENS device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the implantation of the peripheral nerve stimulation (PENS) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed (E0302). 
 
You asked the Plan to pre-approve an extra heavy-duty hospital bed (E0302). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria 
for the requested extra heavy-duty hospital bed (E0302). 
 
The Plan must follow Medicare rules. The rules say an extra heavy-duty hospital bed (E0302) is covered if the 
beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds. 
 We looked at the file and Medicare rules. The file shows that your current weight is less than 600 pounds. This 
means that you do not meet criteria for the extra heavy-duty hospital you have requested. Therefore, we 
decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed (E0302).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after May 5, 
2022. 
 
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before May 5, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after May 5, 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 lab testing services provided on November 30, 2021. 
 You asked the Plan to pay for the lab services. You say that the testing was necessary for the management of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says there is no evidence to support the 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary 
sufficient information to determine whether payment is due. 
 
We looked at the file and Medicare rules. The records do not show that the testing was ordered by the 
enrollees treating physician. Based on this information, we decided that the Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cochlear implant (L8621), provided on November 23, 
2021. 
 
You asked the Plan to pay for the cochlear implant. You say that the item should be covered. The Plan denied 
your request. The Plan says you obtained this item through a provider who is not enrolled in Medicare. 
 
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 cochlear implant (L8621), provided 
on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on May 6, 
2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the medical records should 
be reviewed to reprocess the claim for reimbursement. The Plan denied your request. The Plan says procedure 
code 76942 has been overturned and procedure code 99100 remains denied as bundled services are not eligible 
for separate reimbursement.  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency anesthesia (99140) provided on September 3, 
2021. 
 
You asked the Plan to pay for emergency anesthesia (99140). You say that the anesthesia record should be 
reviewed for reprocessing of the claim for payment. The Plan denied your request. The Plan says procedure 
code 00840 has been overturned and procedure code 99140 remains denied as bundled services are not eligible 
for separate reimbursement.  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 99140 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99140 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of emergency anesthesia (99140) have not been met. Therefore, we decided that the Plan does not have to pay 
for emergency anesthesia (99140) provided on September 3, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve polysomnography testing (95810, 95811). 
 
You asked the Plan to pre-approve polysomnography. You say that the enrollee is at risk for obstructive sleep 
apnea (OSA) due to loud snoring and hypertension. The Plan denied your request. The Plan says that the 
enrollee does not have adequate symptoms of sleep apnea to justify the necessity of polysomnography. The 
enrollee is not experiencing excessive daytime sleepiness and fatigue, no witnessed apnea, no choking during 
sleep witness or loud snoring. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 polysomnography. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the enrollee has presented with signs and symptoms suggestive of OSA. These 
include loud snoring and non-restorative sleep. The enrollee is also noted to be obese and hypertensive. In such 
a clinical context, these findings when put together would suggest the presence of OSA. Therefore, the enrollee 
can be said to have an indication for which the NCD supports the use of sleep testing. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have been met. Therefore, we decided that the Plan has to 
pre-approve polysomnography testing (95810, 95811).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for your 
care. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and it is 
currently unstable for you to be transferred to an LTACH. 
 
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 do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care facility. There are no services available at the LTACH that you require that is not available at the 
health care setting being offered by the health 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute 
care and does not require transfer to a LTACH. 
 
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 enrollee does not require services at the LTACH that are not available at the acute care hospital where 
he is currently receiving care. All medically necessary care is being provided in the current acute care facility. 
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 health plan has approved ongoing care in the current acute care facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on February 
5, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). The Plan denied your request. The Plan 
says procedure code 00670 has been overturned and procedure code 99100 remains denied as bundled services 
are not eligible for separate reimbursement.  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on June 2, 2021. 
 
You asked the Plan to pay for the testing services. You say that you were compliant with regulations for billing. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 
 
 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the panel testing provided on June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Truxima (Q5115). 
 
You asked the Plan to pre-approve Truxima. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested drug has been prescribed for an off-label and medically unsupported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Truxima. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Truxima (Q5115).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 25, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening services 
are not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary 
sufficient information to determine whether payment is due and the amount of payment. 
 
 We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
testing was ordered to treat a specific medical problem. The testing at issue is not covered for screening 
purposes. The file shows that the Plan made multiple attempts to obtain additional information without success. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on January 18, 2021. You asked the Plan to pay for the testing services. You say that the testing gives deep insight into appropriate 
treatment options. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The gene panel was billed with multiple codes. If a single procedure is 
performed, only one code with one unit of service may be reported for the procedure. The claim was billed with 
the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Based 
on this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene panel provided on January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom sensor. 
 
You asked the Plan to pre-approve the Dexcom sensor. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
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 the Dexcom sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
Dexcom sensor.