Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0402, G0463) provided on April 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
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 codes G0402 and G0463 is not supported in the medical record. Specifically, these 
codes returned OCE edit 42, which indicates that multiple medical visits were billed on same day with same 
revenue code without condition code G0. Condition code G0 is required in this case for payment to be considered. 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 pay for the services (G0402, G0463) provided 
on April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a disc allograft intervertebral disc augmentation 
procedure (0627T). 
 
You asked the Plan to pre-approve the disc allograft intervertebral disc augmentation. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental 
and is non-covered. 
 
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 disc allograft intervertebral disc 
augmentation. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective or safe treatment for the noted pathology. 
 
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 disc allograft intervertebral disc augmentation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a disc allograft intervertebral disc augmentation 
procedure (0627T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Sprint Peripheral Nerve Stimulator 
(PNS). 
 
You asked the Plan to pre-approve implantation of the Sprint PNS. 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 no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless 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 implantation of the Sprint PNS. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has 
degenrative back pain without radiculopathy. PNS devices are experimental for back pain without radiculopaty. 
More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of the Sprint PNS have not been met. Therefore, we decided that 
the Plan does not have to pre-approve implantation of the Sprint Peripheral Nerve Stimulator (PNS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this service is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 enrollee does not require the intensity of services provided at an IRF.   
 Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of approval for 
inpatient rehabilitation services due to mononeuropathies. The Plan denied your request. The Plan says based 
on Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 you do not require the intensity of services provided at an IRF. You have not 
shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital 
care is medically necessary. The Plan denied your request. The Plan says the requested hospital stay isn't 
covered because it's associated with a procedure that isn't covered. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care has been met 
in this case. Our physician reviewer found the enrollee is experiencing pain in her Left shoulder, affecting 
ADLs. Imaging and clinical exam support glenohumeral osteoarthritis. She has tried and failed conservative 
measures. She is medically stable with a past medical history of GERD, HTN. The planned procedure listed 
under CPT codes 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as 
an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will 
require a greater than 2 midnight stay. The review has determined that the record did not show that at the time 
of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Varubi 90mg tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this medication is not covered under the enrollee's 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Varubi 90mg tablet 
medication.  
 Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ACCU-Chek Aviva Plus strips (CPT code A4253). 
 
You asked the Plan to pay for the strips. You say that the strips are necessary. The Plan denied your request. 
The Plan says the criteria have not been met for the non-preferred strips. 
 
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 strips. Our physician reviewer found in order for non-preferred strips to be covered, the enrollee must have tried and failed the covered strips or have a 
reason why using the preferred strips would be impossible or would be likely to result in poor outcomes. There 
is insufficient data to support that this is the case with the ACCU-Chek strips in this case as the enrollee has not 
tried the preferred brand. 
 
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 strips have not been met. Therefore, we decided that the Plan does not have 
to pay for ACCU-Chek Aviva Plus strips (CPT code A4253).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a bi-ventricular defibrillator (CRT-D). 
 
You asked the Plan to pre-approve implantation of a CRT-D. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 implantation of a CRT-D. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee would not qualify for defibrillator implantation based on current 
Medicare criteria. In summary, there is insufficient documentation to support the medical necessity for 
implantation of a CRT-D in this enrollees management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a CRT-D have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantation of a bi-ventricular defibrillator (CRT-D).
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 the IRF is the best option for you to regain strength 
and progress from this point on. 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 your 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service December 3, 
2021, to December 14, 2021. 
 
You asked the Plan to pay for procedure code 99255. You say that these services are supported as billed. 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 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service December 3, 2021, to December 14, 2021.
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 the enrollee requires close physician oversight in an 
IFR setting. 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: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted molecular pathology procedure, GeneSight 
gene panel (81479).  
You asked the Plan to pre-approve the laboratory service. You say that the medical records provided support 
the necessity of the requested services in dispute. The Plan denied your request. The Plan says there is not 
enough clinical information to determine if the service requested is 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 laboratory service. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation indicates that the enrollee has depression and anxiety. 
The records show that the same provider ordered another GeneSight test on the enrollee and it was reported out 
on January 20, 2021. An office note from the provider dated July 20, 2022, says the enrollee's "mood is 
somewhat poor" and therapy is being considered. There is no specific clinical rationale for another test. The 
review has determined that the records do not show that the enrollee meets the medically necessary criteria for 
Medicare coverage. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve unlisted molecular pathology procedure, GeneSight gene panel (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that your doctor knows that you 
need oxygen every minute. You say that you do not know what to do. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. There is no further payment for oxygen equipment during the 5-year reasonable 
useful lifetime (RUL) of the equipment after 36 rental payments have been made. 
 
We looked at the file and Medicare rules. The records show that the Plan has paid for 36 months of rental costs 
for a portable oxygen concentrator, which stared on August 5, 2019. The supplier who provided the equipment 
during the 36th rental month is required to continue to provide the equipment, accessories, contents, 
maintenance, and repair of the oxygen equipment during the 5-year reasonable useful lifetime of the 
equipment. Based on this information, we decided that Medicare rules for coverage of a portable oxygen 
concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
payment for a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provided records did not clearly show that this enrollee has an unstable 
condition or that the procedure is particularly high risk for complication. There was insufficient evidence 
provided suggesting the enrollee would need hospital treatment that would likely cross 2 midnights. 
Consideration for inpatient admission can always be considered during or after surgery if needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infectious disease pathogen panel (87496, 87498, 87486, 
87502, 87532, 87541, 87581, 87634, 87640 and 87798) provided on April 26, 2022. 
 
You asked the Plan to pay for infectious disease pathogen identification testing. You say that this testing was 
necessary and is supported in the medical record. The Plan denied your request. The Plan says this test is not 
medically necessary as the enrollee does not have severe and established underlying respiratory pathology. The 
enrollee has no asthma exacerbation with fever or purulent sputum or radiographic evidence of pneumonia. In 
addition, this panel was not billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show 
that a single panel was ordered and performed, but this service was billed by reporting individual components. 
Therefore, we decided that the Plan does not have to pay for an infectious disease pathogen panel (87496, 
87498, 87486, 87502, 87532, 87541, 87581, 87634, 87640 and 87798) provided on April 26, 2022.