Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested injections. You say that this is medically necessary to treat the 
enrollee's pain. The Plan denied your request. The Plan says the notes do not show that other sources of pain 
have been ruled out as required. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered when the LCD 
rules 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 requested injections. Our reviewer 
says that the requested injections are not shown to be reasonable and necessary based on LCD guidelines. Our physician reviewer found the enrollee has chronic neck pain treated with naproxen and Ultram. He has tried 
physical therapy. Though the physical exam does suggest facet mediated pain, there is no advanced imaging 
reports to support this diagnosis or rule out other pathology. Therefore, at this point, the request is deemed 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 requested injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 10 months rental of a ventilator. 
 
You asked the Plan to pre-approve additional 10 months rental of a ventilator. 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 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 additional 10 months rental of a 
ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found in 
this case, the record indicates that the enrollee has chronic respiratory failure from chronic obstructive 
pulmonary disease. The record indicates that the enrollee was successfully treated with bilevel positive airway 
pressure (BiPAP) after extubation. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine with average volume-assured pressure support (AVAPS) capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
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 additional 10 months rental of a ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional 10 months rental of a ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home blood draws. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not homebound or receiving any skilled services. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that first of all, the 
requested lab draw is not shown to be medically necessary.  The enrollees prostate specific antigen (PSA) is 
known to be elevated. The enrollee is not receiving any treatment for same due to his fragile health. Repeat 
PSA testing is unlikely to affect the enrollees care. As such, the test is not medically necessary or reasonable. 
Additionally, the enrollee does not have any documented home health skilled nursing needs. Blood draws alone 
are not an indication for home health services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home blood draws.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would benefit from skilled nursing services due 
to your medical complexity. The Plan denied your request. The Plan says you do not meet criteria for SNF 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no medical indication to do both magnetic resonance imaging (MRI) of the 
pelvis and computed tomography (CT) scan of the pelvis. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the services. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that in this patient with a 
likely anal/rectal carcinoma the possibility of metastatic disease in the chest, abdomen and pelvis is high due to 
lymphatic drainage in this area of the pelvis. The magnetic resonance imaging (MRI) of the pelvis makes sense 
for initial diagnosis and staging and should be approved. The CT of the chest and abdomen should be approved 
for staging. Finally, the CT of the pelvis is not necessarily indicated for initial staging if MRI of the pelvis is 
done, however, this portion of the CT will be important to establish the baseline of the pelvis which will be 
useful for the follow-up scans after therapy which are inevitable and likely to be CT scans. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) scan of the abdomen and pelvis.  
 
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 pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found according to the 
coverage criteria: It is not considered medically reasonable and necessary to perform multiple blocks (ESIs, 
sympathetic blocks, facet blocks, trigger point injections, etc) during the same session as ESIs, with the 
exception of a facet synovial cyst and ESI performed in the same session. The review has determined that the 
enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the tests should 
be included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81479) billed for date of service June 2, 
2022. 
 You asked the Plan to pay for laboratory services. You say that this testing was necessary and appropriate. The 
Plan denied your request. The Plan says this claim was submitted with an inappropriate date of service. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record shows that the specimen in question 
is a blood sample which was collected in a non-hospital setting on May 18, 2022. Medicare rules say that 
unless an exception has been met, the date of service billed should be the date the specimen was collected. 
Because the sample was not collected in a hospital setting, an exception has not been met in this case, and the 
appropriate date of service to report would be May 18, 2022, rather than the billed date of June 2, 2022. 
Therefore, we decided that the Plan does not have to pay for laboratory testing (81479) billed for date of 
service June 2, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 94640 and 93005 provided on July 4, 2022. 
 
You asked the Plan to pay for codes 94640 and 93005. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 find that CPT codes 94640 and 93005 are not supported in the medical record. Specifically, these codes 
have a status indicator of Q1. Code 99285 was billed on the same date of service with a revenue code of 450 
which has a status indicator of "V". This means codes 94640 and 93005 are not separately payable. Based on 
this information, we decided that Medicare rules for coverage of codes 94640 and 93005 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 94640 and 93005 provided on July 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4649 billed for date of service July 18, 2022. 
 
You asked the Plan to pay for code A4649. The Plan denied your request. The Plan says code A4649 is 
considered bundled and not separately payable. 
 
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 code A4649 has a status indicator of P on the Physician Fee Schedule. This means that code 
A4649 is not separately payable. Based on this information, we decided that Medicare rules for coverage of code A4649 have not been met. Therefore, we decided that the Plan does not have to pay for code A4649 billed 
for date of service July 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection rendered on June 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 96372 has an OPPS status indicator of Q1 and 
was billed with code 99284, which has an OPPS status indicator of V. Code 96372 is therefore not separately 
payable. Therefore, we decided that the Plan does not have to pay for the injection rendered on June 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has a prostate volume of 184cc by transrectal ultrasound (TRUS) and a 
known history for bladder 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that all of the coverage criteria have not been met. Prostate size is not 30-150cc. Maximum 
urinary flow rate (Qmax) was not provided. The International Prostate Symptom Score (IPSS) was not 
provided.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral waterjet ablation of the prostate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 11, 2022, to 
April 21, 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 you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 diagnosis code E43, defined as severe malnutrition. 
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 documentation does not support the diagnosis billed. Our physician 
reviewer found the enrollee presented to the emergency department for abdominal pain once again with 
diarrhea for several days. The enrollee was managed with IV fluid. Protein calorie malnutrition (PCM) is the 
state of inadequate intake of food (as a source of protein, calories, and other essential nutrients) occurring in the 
absence of significant inflammation, injury, or another condition that elicits a systemic inflammatory response. 
In this case there was no evidence of PCM. The review has determined that the diagnosis E43, severe 
malnutrition was not supported by the documentation. 
 
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 11, 2022, to April 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic test provided on June 10, 2022. 
 
You asked the Plan to waive the copayment for diagnostic test. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $50 copayment for diagnostic test. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for diagnostic test provided on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is the enrollee's best chance to regain ambulatory 
status. The Plan denied your request. The Plan says the request 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve hematolymphoid neoplasm gene panel testing of 51 genes. 
 
You asked the Plan to pre-approve the panel testing. You say that the testing is needed to aid the best treatment 
option for bicytopenia. The Plan denied your request. The Plan says that the testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the panel testing. Our physician 
reviewer found that the enrollee has anemia and thrombocytopenia. The bone marrow biopsy is suspicious for 
chronic myelomonocytic leukemia (CMML). The molecular panel will help diagnose and guide therapy 
decision making. The requested use is recommended by the National Comprehensive Cancer Network (NCCN) 
Guidelines. The review shows that the testing is medically reasonable and necessary to treat the 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 the panel testing have been met. Therefore, we decided that the Plan has to pre-
approve hematolymphoid neoplasm gene panel testing of 51 genes.  
 
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.