Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
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 the clinical documentation does not completely specify the functional 
impairments or the etiology of the impairment. The clinical documentation does not specify any active medical comorbidities. Thus, the complexity of the enrollee's documented nursing, medical, and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. IRF criteria not met. 
 
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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 request is not medically necessary, and the enrollee is receiving 
appropriate care at the current hospital. 
 
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 enrollee is improving but is not yet stable for transfer. The enrollee should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until 
they are more stable for a lower level of care. Completion of treatment at the current facility is recommended. 
 
 
  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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IMRT (77386 and 77387). 
 
You asked the Plan to pre-approve the IMRT. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's medical records do not show any direct evidence that this type 
of radiation therapy is needed or effective for the enrollee's rectal cancer. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT would not be considered to be furnished in accordance with accepted standards or 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 the IMRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IMRT (77386 and 77387).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee is not participating in an approved clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS covers leadless pacemakers when 
procedures are performed in Food and Drug Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-
approve a leadless pacemaker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary, and the services can safely be provided in other 
settings. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
While they continue to have a need for skilled therapy, the documentation does not support that the enrollee 
would meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can receive further 
services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (83521) provided on March 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you expected these services to be paid because 
they had been covered for all of 2021. You say there may be a coding issue, but these are the same services you 
had been receiving previously. The Plan denied your request. The Plan says that these services are considered 
experimental/investigational and are considered not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for laboratory services by a contract provider. The file does not show that the Plan provided 
notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory services (83521) 
provided on March 10, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a head injury, is currently 
hospitalized and needs additional tests. You say that the enrollee is not ready to be discharged and needs 
rehabilitation. The Plan denied your request. The Plan says the request is not medically necessary, and the 
enrollee can receive the services in other settings. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
they continue to have a need for skilled therapy, the documentation does not support that the enrollee would 
meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can receive further services 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated seat cushions (E2609, E2617). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that custom fabricated cushions may be covered if the 
certain criteria are met.  
 
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 wheelchair accessories. Our 
reviewer says that the requested wheelchair accessories are not medically necessary. Our physician reviewer 
found the provided documentation does not indicate that you do not have a current pressure ulcer or past 
history of a pressure ulcer on the area of contact with the seating surface absent or impaired sensation in the 
area of contact with the seating surface or inability to carry out a functional weight shift. The reviewer also 
found the documentation does not indicate any significant postural asymmetries. Therefore, the reviewer found 
that the requested wheelchair accessories are 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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve custom fabricated seat cushions (E2609, E2617).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77003 and J3490 billed for date of service 
November 18, 2022. 
 
You asked the Plan to pay for procedure codes 77003 and J3490. The Plan denied your request. The Plan says 
payment for codes 77003 and J3490 is bundled. 
 
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 77003 
is a column II code to column I code 64490. 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. 
 
Medicare rules also say that the Medicare approved amount for global surgery procedures includes payment for 
services related to the surgery when furnished by the physician who performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the requested drugs (J3490) is included in the global 
surgery payment for the procedure (64490) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 77003 and J3490 billed for date of service November 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740), and a fixed pontic (D6245). 
 
You asked the Plan to pre-approve a retainer crown and a fixed pontic. You say that you would like the Plan to 
approve and pay for this. The Plan denied your request. The Plan says these services have been correctly 
denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
retainer crown (D6740), and a fixed pontic (D6245).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Caris MI Profile genetic testing (88341, 88360, 81455, 88342). 
 
You asked the Plan to pre-approve Caris MI Profile genetic testing. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are 
experimental/investigational. 
 
The Plan follows Medicare rules. The rules say that NGS testing is reasonable and necessary when the criteria 
listed in the Medicare rules section of this letter have been met. 
 
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 Caris MI Profile genetic testing. Our 
reviewer says that the requested services are medically reasonable and necessary in this case. Our physician 
reviewer found that guidelines for both non-small cell lung cancer (NSCLC) as well as for occult malignancy 
support the use of molecular profiling for treatment decision making. Molecular Diagnostic Studies in both 
situations are considered a standard of care. Broad molecular profiling is a key component of the improvement 
of care of patients with NSCLC and occult malignancy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Caris MI Profile genetic testing have been met. Therefore, we decided that the 
Plan has to pre-approve Caris MI Profile genetic testing (88341, 88360, 81455, 88342).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (up to 
2 hours); each additional hour (99602) and home infusion/specialty drug administration, per visit (up to 2 
hours) (99601) provided on September 14, 2022. 
 
You asked the Plan to pay for procedure code 99601 and 99602. You say that the claim should be paid. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 and 99602 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99601 and 99602 is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99601 and 99602 have not been met. Therefore, we 
decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (up to 2 
hours); each additional hour (99602) and home infusion/specialty drug administration, per visit (up to 2 hours) 
(99601) provided on September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for date of 
service April 29, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, and 88360. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says these codes are included in the facility payment and 
is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 88341, 88342, and 88360 billed for date of service April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge services (99239) provided on May 30, 2022. 
 
You asked the Plan to pay for the discharge services. The Plan denied your request. The Plan says the claim 
was billed incorrectly. 
 
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 payment for CPT code 99239 is not supported in the medical record. Specifically, the inpatient 
discharge code 99239 was billed while the enrollee was under outpatient observation status. It is inappropriate 
to bill an inpatient discharge code while under observation care. Based on this information, we decided that 
Medicare rules for coverage of the discharge services have not been met. Therefore, we decided that the Plan 
does not have to pay for the discharge services (99239) provided on May 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the hotel stay provided from December 11, 2022, 
to December 17, 2022. 
 
You asked the Plan to reimburse you for the hotel stay. You say that you had a radioactive eye patch placed on 
your eye. You say that you need to have it on for 94 hours and removed within 2 hours of the 94 hours being 
up. You say that your doctor advised you needed to say within 30 miles of the hospital and were not to be 
around people. You also say that you live more than 30 hours away from the hospital. The Plan denied your 
request. The Plan says the hotel stay is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hotel stay have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for the hotel stay provided from December 11, 2022, to December 17, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (83521) provided on July 28, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you expected these services to be paid because 
they had been covered for all of 2021. You say there may be a coding issue, but these are the same services you 
had been receiving previously. The Plan denied your request. The Plan says that these services are considered 
experimental/investigational and are considered not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for laboratory services by a contract provider. The file does not show that the Plan provided 
notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory services (83521) 
provided on July 28, 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.