Persius/hicric huggingface dataset:
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 February 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are 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 
February 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide 1 hour a day, 7 days a week. 
 
You asked the Plan to pre-approve a home health aide 1 hour a day, 7 days a week. 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 HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide 1 hour a day, 7 days 
a week. Our reviewer says that the services are not medically necessary. Our physician reviewer found you do 
not appear to be homebound, given your ability to attend multiple outpatient medical appointments. You do not 
have documented home health skilled nursing or home health therapy needs. There is no evidence that home 
health aide services are needed to assist in the treatment of an illness or injury. As such, the requested home 
health aide services are not medically necessary, reasonable or coverable. 
 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 health aide 1 hour a day, 7 days a week have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a home health aide 1 hour a day, 7 days a week.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 19, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81355, 81291, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare guidelines. 
 
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 
April 19, 2022, billed with codes 81227, 81230, 81231, 81232, 81355, 81291, 0031U, 0032U and 0033U.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not on home health, and has not 
received any care since leaving the emergency department. The Plan denied your request. The Plan says the 
enrollee does not require an intensive level of therapy requiring physician oversight. 
 
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 clinical documentation does not show that the enrollee has active comorbidities or 
requires close medical supervision on an inpatient basis. Our reviewer also found that the documentation does 
not show that the enrollee has functional impairments or requires multiple disciplines of therapy, thus IRF 
criteria have not been 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF is recommended at this time. The Plan denied 
your request. The Plan says an intensive rehabilitation program 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 there is no documented active comorbidities that would require close medical 
monitoring on an inpatient basis, thus IRF criteria have not been 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 12, 2022. 
 
You asked the Plan to pay for these services. You say that the second injection should be paid. The Plan denied 
your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that bilateral surgeries are identified by the presence on the 
claim form or electronic submission of the "-50" modifier or of the same code on separate lines reported once 
with modifier "-LT" and once with modifier "-RT." 
 
We looked at the file and Medicare rules. The file shows that billed procedure code 20610 is a bilateral 
procedure. The Plan paid the code per the bilateral surgical payment. Therefore, we decided that the Plan does 
not have to pay for the surgical services rendered on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and are 
supported in the records. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix, per square centimeter (code Q4186) and Skin 
Substitue Grafts (code 15271). 
 
You asked the Plan to pre-approve Epifix, per square centimeter and Skin Substitue Grafts. You say that 
Epifix, per square centimeter and Skin Substitue Grafts is medically necessary. The Plan denied your request. 
The Plan says Epifix, per square centimeter and Skin Substitue Grafts does not meet the Medicare coverage 
criteria. 
 
The Plan must follow Medicare rules.  
  
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 Epifix, per square centimeter and Skin 
Substitue Grafts. Our reviewer says that Epifix, per square centimeter and Skin Substitue Grafts is not 
medically necessary. Our physician reviewer found that the enrollee is a 55-year-old male with type 2 diabetes 
mellitus with a chronic skin ulcer, PVD, and lymphedema. The wound measured 17 x 11 cm in 2019. The 
enrollee was treated with standard treatments including boot, compression wrap, and dressing changes. Recent 
wound measurements were 7 x 1.5 x 0.1 cm. Epifix skin grafting was requested. It appears that the ulcer is 
improving with treatment based on the provided measurements found in the documentation. There was 
insufficient evidence of failed treatment for at least 3 months. Therefore, the patient does not meet criteria 
found in the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix, per square centimeter and Skin Substitue Grafts have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Epifix, per square centimeter (code Q4186) 
and Skin Substitue Grafts (code 15271).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs acute level therapy to regain 
strength and to prevent future readmission to the hospital. The Plan denied your request. The Plan says the 
criteria for admission to the Acute Inpatient Rehabilitation 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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee requires physical therapy and occupational therapy services, but based on the 
documentation provided, it is not clear that the enrollee is ready for an intensive inpatient rehabilitation therapy 
program. Our reviewer also found that there is concern as to whether the enrollee will be able to fully 
participate in, and benefit from, the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2022 to March 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2022 to March 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found based on the 
documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
multiple infections resulting in multiorgan failure. The enrollee was intubated/ventilated and eventually 
received a tracheotomy. The enrollees long-term respiratory goals are unclear. There is no evidence that the 
enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the 
same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at 
the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged 
to a lower level of care for any ongoing long term care needs.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies rendered on December 28, 2021. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The supplies at issue are from a non-preferred provider. The Plan did 
not approve a medical exception for these supplies. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the diabetic testing supplies rendered on December 28, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 64-year-old woman with a diagnosis of Spinal stenosis, lumbar 
region with neurogenic claudication. The enrollee has severe pain without medication. There has been no 
functional improvement provided by a high-volume caudal steroid injection. An MRI has demonstrated 
moderate L4-L5 central canal stenosis. In this case, the enrollee has severe pain without medication, and has 
failed conservative treatment, including physical therapy, medications, and injections. Interspinous spacer 
interventions for symptomatic lumbar spinal stenosis have been shown in the medical literature to be safe and 
effective through 5 years of follow-up. The Vertiflex procedure with the Superion interspinous spacer system 
has received Food and Drug Administration premarket approval for treating this enrollee's condition and there 
is sufficient supportive documentation to justify use. 
 
 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 Vertiflex procedure have been met. Therefore, we decided that the Plan does 
not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 10, 2022, billed 
with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, 0033U and 
81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare guidelines. 
 
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 
February 10, 2022, billed with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 
0031U, 0032U, 0033U and 81407.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 16, 2022. 
 You asked the Plan to pay for the lab services. You say that the test reduces the risk of a delayed diagnosis. The 
Plan denied your request. The Plan says how the enrollee came to the servicing provider is unable to be 
determined. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that there are insufficient medical records by the enrollees treating physician to show that the testing 
was ordered to treat a specific medical problem. The testing is not covered for screening purposes. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab services provided on March 16, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a placement of penile implant. 
 
You asked the Plan to pre-approve a placement of penile implant. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage for the 
requested service have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program payment may be made for diagnosis and 
treatment of sexual impotence. 
 
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 placement of penile implant. Our 
reviewer says that the requested service is medically reasonable and necessary in this case. Our physician 
reviewer found that the available records show that the enrollee has failed medical treatments and has organic 
impotence and not psychological impotence. 
 
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 placement of penile implant have been met. Therefore, we decided that the 
Plan has to pre-approve a placement of penile implant.  
 
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.