Persius/hicric huggingface dataset:
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patients nursing medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient is currently residing at home, and she has not had a significant change in her baseline medical conditions. She does not require the intensity of 
rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. She does not require 
rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, or tracheostomy 
management. Her medical and rehabilitation needs do not require the intensive interdisciplinary approach 
provided on acute inpatient rehabilitation. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on December 14, 2021. 
 
You asked the Plan to pay for drug testing. You say that you disagree with the denial of this claim. You have 
submitted medical records for review and reconsideration of payment on this claim. 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. The records show that the submitted claim form indicates the 
laboratory specimen was taken in a laboratory, POS 81, however, the submitted medical records indicate the 
specimen was obtained in an office setting POS 11. Based on this information, we decided that Medicare rules 
for coverage of the drug testing 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 drug testing provided on December 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
provided on January 28, 2022. 
 
You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that you 
awoke on January 28, 2022 with a strange feeling in your body and after this feeling did not subside, you called 
911 and an ambulance was sent. You say that they checked you out but you did not feel any better so you were 
transported to the hospital. The Plan denied your request. The Plan says there is no documentation of a life-
threatening emergency. The member could have been safely transported to the emergency department by 
another means of transportation. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same 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 pay for ambulance service, basic life support, 
emergency transport. Our reviewer says that ambulance service, basic life support, emergency transport was 
not medically necessary. Our physician reviewer found that based on the medical records provided your 
presenting symptoms did not appear to meet a prudent layperson's criteria for emergency care. The provided 
records do not document pain, dyspnea, nausea, vomiting or any abnormal vital signs of physical examination 
findings other than the appearance of fatigue at time of the ambulance transport. The provided records do not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of 
vehicle) were contraindicated for you. The provided records do not support that you needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe 
transport. The provided records do not support that the ambulance transport meets Medicare criteria for 
medically reasonable and 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 ambulance service, basic life support, emergency transport have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency 
transport (A0429, A0425) provided on January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services you received on January 12, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says screening testing is not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
 
 The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services you received on January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound image guided radiotherapy (G6001). 
 
You asked the Plan to pre-approve ultrasound image guided radiotherapy. You say that the requested service is 
medically necessary. The Plan denied your request. The Plan says the service at issue 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 ultrasound image guided radiotherapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the treatment using electronic brachytherapy is not at issue in this case, 
but that the issue is the need for image-guided radiotherapy (IGRT). IGRT is a means to improve set-up 
accuracy. IGRT uses daily image guidance to help localize the target so as to minimize normal tissue dosing. 
Specifically, IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the 
margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation.   
 
   
Usually, IGRT is used when critical structures are abutting or in close proximity to the target that is being 
treated to high doses. This situation does not apply to this patient for which the target lesion can be seen on the 
skin to assist in daily set up. While the use of ultrasound on a daily basis during radiation therapy is not 
unreasonable, it is found that payment for these simple daily simulations is not supported as the clinical need 
for this is not established by published data or supported by consensus guidelines. This is not considered 
medically necessary as it is not to be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound image guided radiotherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ultrasound image guided radiotherapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA), nerves innervating the 
sacroiliac (SI) joint, (64625) bilateral. 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee has had multiple injection to their SI 
joint. You say that they have provided limited relief and most recently for only a few days. You also say that 
the requested RFA has been shown to provide at least 6 months of pain relief in some patients. The Plan denied 
your request. The Plan says the requested RFA 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 RFA. Our reviewer says that the 
requested RFA are not considered medically reasonable and necessary in this case. Our physician reviewer 
found he requested procedure is considered experimental and investigational due to the wide variation in 
efficacy. Therefore, 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA), nerves innervating the sacroiliac (SI) joint, (64625) bilateral.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 13, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenetics testing is covered for the 
indications established in the applicable LCD. 
 
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 testing. Our reviewer says that the requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that 
there is no documentation from the provider documenting the drugs the enrollee is considering for use, and no 
documentation as to how the results will impact treatment. The requested testing is not medically reasonable or 
necessary according to the coverage criteria established 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on February 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for the outpatient surgery and self-administered 
drugs provided from November 29, 2021, through November 30, 2021. 
  You asked the Plan to reduce the cost for the outpatient surgery and self-administered drugs. You say that the 
medicine prescribed was necessary after surgery and the decision to deny this claim should be reconsidered. 
The Plan denied your request. The Plan says the claim processed 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). The rules say that Medicare Part B generally does not pay for self-
administered drugs. 
 
You have been asked to pay a $250 copayment for the outpatient surgery and $51.55 for the self-administered 
drugs. The outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital 
Facilities and Ambulatory Surgical Centers benefit category. The self-administered drugs remain denied as 
non-covered under Part B. 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 reduce the cost for the outpatient surgery and self-
administered drugs provided from November 29, 2021, through November 30, 2021.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 4, 
2021. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
codes 01740, 64415 and 76942 have been paid. The Plan also says procedure code 99100 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 procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 4, 2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 enrollee is unable to participate in intensive rehabilitation and respond. Evidence based literature has shown intensive rehabilitation is not medically necessary for hip fracture 
rehabilitation. There is no indication for frequent physiatry oversight. There are no complex medical barriers to 
routine post hip fracture rehabilitation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 2, 2021. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says it is the 
providers responsibility to bill the Primary Group Health Plan or any liability insurance before submitting the 
claim to the members Plan. The Plan did not receive the primary carriers Explanation of Benefits. 
 
 
 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. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the primary carriers Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for 
physical therapy services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided on December 2, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not have complex care needs which can only be provided in this 
setting. 
 
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. There 
are no acute rehab nursing needs identified or documented. At the current functional level, you do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. While you may benefit from continued physical and occupational 
therapy, your rehab needs can be safely provided in a lower intensity and alternate setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of lumbar degenerative disc disease have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a commode chair (E0168), supplies (99070), a shower chair 
(E0240), and a folding walker (E0143) provided January 2, 2022 to February 16, 2022. 
 
 
You asked the Plan to pay for the items. You say that these items were medically necessary and purchasing 
through Amazon saved money. The Plan denied your request. The Plan says payment cannot be made for items 
that are purchased from a supplier that is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The 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 pay for a commode chair (E0168), supplies 
(99070), a shower chair (E0240), and a folding walker (E0143) provided January 2, 2022 to February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81599) provided on May 2, 2022. 
 
You asked the Plan to pay for PrismRA testing. You say that these services were necessary and were performed 
by a certified laboratory. The Plan denied your request. The Plan says this test is not covered by Medicare as it 
is not approved by the Food and Drug Administration (FDA). 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81599) provided on May 2, 2022.