Persius/hicric huggingface dataset:
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 you are requesting an expedited reconsideration as 
the enrollee currently meets full IRF criteria. The Plan denied your request. The Plan says criteria for admission 
to the IRF setting 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 You asked the Plan to pre-approve Retacrit. You say that Procrit and Epogen are the same drug. The Plan 
denied your request. The Plan says there is no record that shows the enrollee has tried one of the preferred 
drugs, Aranesp or Procrit, and it has not worked, or that the enrollee has medical reasons that prevent them 
from using one of them. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the 
enrollee does not meet the coverage criteria for Retacrit. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred 
step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested service cannot be 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 3, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that you disagree with the 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 when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has been using this equipment 
and doing well with it. The enrollee had to go to the clinic because she was not able to have the equipment. The 
Plan denied your request. The Plan says the records do not show that the requested device will not be used 
exclusively in a bi-level PAP mode. The noninvasive ventilator is ordered in a mode called volume assured 
pressure support (VAPS), and this can be achieved with bi-level devices such as a BiPAP machine. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, although 
there are no pulmonary function tests to assess severity. The enrollee has had repeated recent hospitalizations 
for the COPD. ABGs in March of this year were consistent with acute on chronic hypercarbic respiratory 
failure.  This enrollee may benefit from BiPAP with AVAPS during sleep.  Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick Urine Collection System. 
 
You asked the Plan to pre-approve a Purewick Urine Collection System. You say that the enrollee needs this 
device for urinary incontinence. The Plan denied your request. The Plan says the provider who supplies this 
device does not participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare 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 pre-approve a Purewick Urine Collection 
System.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical assistant services billed with code 27486-AS-50 for date of 
service August 8, 2022. 
 
You asked the Plan to pay for the surgical assistant services. You say that you have provided medical records 
to support payment. The Plan denied your request. The Plan says that although documentation was requested, 
no documentation was provided showing that the provider of service was a Physician's Assistant, Nurse 
Practitioner, or Clinical Nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that it could not confirm that 
the provider of service was a valid provider type to bill for surgical assistant services.  We do not find this 
persuasive. The simplest of Google searches clearly shows that the provider of service is a Physician's 
Assistant.  The Plan could have easily obtained this information as it is publicly available.  The burden is on the 
Plan to show why its denial was appropriate. The failure of the Plan to perform this basic level of research 
means that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for surgical 
assistant services billed with code 27486-AS-50 for date of service August 8, 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: Favorable

 
We decided that the Plan has to pay for inpatient rehabilitation hospital services provided from December 20, 
2021, to January 6, 2022. 
 
You asked the Plan to pay for the inpatient rehabilitation hospital services. You say that workers' compensation 
denied this claim. The Plan denied your request. The Plan says that the medical records do not show that this 
stay was not the result of a work-related injury. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers.  In this case, the Plans sole rationale for denial is that it 
claims that the services in dispute should be covered by the patients Workers Compensation insurance.  
However, the Plan has provided absolutely no documentation regarding the claim sent to Workers 
Compensation.  The Plan has provided no documentation showing what Workers Compensation determined 
was the actual injury for which there may be coverage. The burden is on the Plan to show why its denial was 
correct. In this case, the Plan has failed to provide evidence of any communications, documentation, or 
explanation as to the Workers Compensation denial and the extent of coverage potentially available under that 
program. Without this information, we cannot determine if the claim should legitimately be paid by Workers 
Compensation or by the Plan. Therefore, we decided that the Plan has to pay for inpatient rehabilitation 
hospital services provided from December 20, 2021, to January 6, 2022. The Plan has the right to try to recoup 
any payments they believe Workers Compensation may owe directly from them, and any such determination 
regarding this it outside of the scope of our review. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous airway pressure (CPAP) device (E0601). 
 
You asked the Plan to pre-approve a CPAP. You say that the item is medically necessary. The Plan denied your 
request. The Plan says that the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that continued coverage of a positive airway pressure 
(PAP) device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st 
day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-
evaluation and document that the beneficiary is benefiting from PAP therapy. 
 
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 a CPAP. Our reviewer says that the 
member does meet criteria for this device. Our physician reviewer found this patient has obstructive sleep 
apnea documented on a sleep study on April 16, 2022. CPAP was prescribed in May 2022. CPAP was started 
by the patient in October 2022. The patient was seen in follow-up a few days after starting CPAP, and benefit 
was documented. A compliance report covering October 7 to November 5, 2022, shows the patient used the 
device for at least 4 hours per night for 70% of nights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CPAP have been met. Therefore, we decided that the Plan has to pre-approve 
a continuous airway pressure (CPAP) device (E0601).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for July 28, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for procedure code 99212 billed for July 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 24, 2022, to 
April 27, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of secondary diagnosis code J96.01. The Plan denied your request. The Plan 
says the medical records do not support the billing of secondary diagnosis code J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.01. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the medical records do not support the billing of secondary diagnosis code J96.01. Our physician reviewer 
found there was no clinical or laboratory evidence of acute respiratory failure with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 24, 2022, to April 27, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73110, 73060, and 73090 billed for April 1, 
2022. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 18, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 73110, 73060, and 73090 billed for April 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
28, 2022. 
 You asked the Plan to pay for procedure code 86077. You say that you disagree with the 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 when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 5, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406, 
81437 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported as billed. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
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 
August 5, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81351, 81406, 81437 and 81479.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing service, 5 visits per week, from 
December 8, 2022, to February 5, 2023. 
  
You asked the Plan to pre-approve home health services. You say that services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
records do not show that skilled nursing services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollees condition and/or prevent deterioration. The records do not show that skilled therapy 
services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
level of function, or to establish/perform a maintenance program to maintain the patient's level of function 
and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing service, 5 visits per week, from December 8, 2022, to 
February 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). 
 
You asked the Plan to pre-approve an injection procedure. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for a therapeutic sacroiliac injection is not medically necessary. 
The documentation sent does not provide any documentation of persistent pain relief, or of increasing 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 an injection procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have a history of chronic low back and hip pain due to lumbar spondylosis, 
without myelopathy or radiculopathy. You have been treated with medications, physical therapy, chiropractic 
care, facet joint injections, radiofrequency ablation and a left sacroiliac joint injection. Sacroiliac (SI) joint 
injections are recommended as an option if you have failed at least 4-6 weeks of aggressive conservative 
therapy including, physical therapy (PT), home exercise and medication management. There should be 
evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. At least three (3) positive 
exam findings of SI joint dysfunction should be present on physical exam such as Patrick's test, thigh thrust, SI 
compression test, Yeoman's test, or Gaenslan's test. In this case, there is no documentation on physical 
examination of three (3) or more positive tests results. The clinical value and effectiveness of an SI joint 
injection in the absence of tenderness and negative provocative testing results have not been demonstrated in 
the peer-reviewed literature. The review has determined that you do not meet criteria for the requested 
injection. The service at issue is 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 an injection procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography when performed (27096).