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. 
 
You asked the Plan to pre-approve IRF care. You say that the clinical documentation provided supports the 
need for IRF care. You say that the enrollee has rehabilitation needs to improve strength, endurance, activities 
of daily living, and mobility. You say that the enrollee has medical needs that necessitate the daily medical 
oversight provided in an IRF. You say that the enrollee is motivated to improve and will tolerate the three 
house of therapy required of acute rehabilitation. The Plan denied your request. The Plan says the enrollee does 
not require intensive medical treatment for his brain injury. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a stroke. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
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 reimburse you for chiropractic manipulative treatment (98940) and 
chiropractic manipulation of one or more of the extra-spinal regions (98943) provided from June 2, 2021, 
through November 22, 2021. 
 
You asked the Plan to reimburse you for chiropractic manipulative treatment (98940) and chiropractic 
manipulation of one or more of the extra-spinal regions (98943). The Plan denied your request. The Plan says 
you did not meet your yearly $500 deductible. 

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 $500 
deductible. 
 
You have been asked to pay $500 deductible for chiropractic manipulative treatment (98940) and chiropractic 
manipulation of one or more of the extra-spinal regions (98943). Chiropractic manipulative treatment (98940) 
and chiropractic manipulation of one or more of the extra-spinal regions (98943) falls within Plan deductible 
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 reimburse you for chiropractic manipulative treatment 
(98940) and chiropractic manipulation of one or more of the extra-spinal regions (98943) provided from  
June 2, 2021, through November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81404 and 81479) 
provided on May 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services (CPT code(s): 81404 and 81479) provided on May 
6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this 
feature does not meet a medical need. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the upper and lower jaw radiographic images (x-ray) 
(D0330), provided on December 13, 2021. 
 
You asked the Plan to pay for the x-rays. You say that the service should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the upper 
and lower jaw radiographic images (x-ray) (D0330), provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the therapy services provided from March 29, 
2021, to September 13, 2021. 
 
You asked the Plan to reimburse you for the services provided. You say that manual therapy has a zero 
copayment. The Plan denied your request. The Plan says you are responsible for the copayment. 
 
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 a $30 
copay per visit for routine chiropractic services.  
 
We looked at the file and the rules. The records show that you received routine therapy services from a 
chiropractor. You were reimbursed the Medicare allowed amount minus the copay outlined in your contract.  The services fall within the routine chiropractic services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not 
have to further reimburse you for the therapy services provided from March 29, 2021, to September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (CPT code G0482) provided on April 7, 2021. 
 
You asked the Plan to pay for the drug test. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the drug test have not been met. CPT code G0482 remains not 
supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when 
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a 
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified. It is noted 
multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the 
Plan does not have to pay for the drug test (CPT code G0482) provided on April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix (belatacept) 1MG injection (CPT code J0485). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the provider requested Nulojix to treat the members Medicare covered 
transplant. The Plan states they determined the drug is not being prescribed within medically accepted 
standards. The Plan states the accepted use of this drug in the enrollee's case requires that Nulojix (belatacept) 
will be used in combination with basiliximab (Simulect) induction, mycophenolate mofetil, and corticosteroids. 
The Plan states the information provided does not indicate that the member has received basiliximab (Simulect) 
induction. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer 
found the reviewed documentation indicates that the provider requested Nulojix to treat the enrollees Medicare 
covered transplant. The use of this drug in this case requires Nulojix (belatacept) will be used in combination 
with basiliximab induction, mycophenolate mofetil, and corticosteroids in patients who are Epstein-Barr virus 
(EBV) seropositive. The information submitted indicates the enrollee is Epstein-Barr virus (EBV) seronegative 
or has unknown EBV serostatus and are not using Nulojix in combination with basiliximab induction or 
corticosteroids. The review has determined that the documentation does not support that the Nulojix 
(belatacept) 1MG injection (CPT code J0485), is medically reasonable and necessary for the enrollee. The 
documentation does not support that the Nulojix (belatacept) 1MG injection is safe and effective for 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nulojix (belatacept) 1MG injection (CPT code J0485).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (CPT code G0480) provided on June 7, 2021. 
 
You asked the Plan to pay for the drug test. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the drug test have not been met. CPT code G0480 remains not 
supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when 
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a 
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on June, 7, 2021, and received by the lab on June 9, 2021. Of note, the patient resides 
in Colorado (CO) and the billing laboratory is located in California (CA); therefore, the billed code cannot be 
verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, 
we decided that the Plan does not have to pay for the drug test (CPT code G0480) provided on June 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) physical therapy visits. 
 
You asked the Plan to pre-approve five (5) physical therapy visits. You say that you require additional physical 
therapy visits. The Plan denied your request. The Plan says that detail is lacking in the skills that require further 
treatment. 

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 five (5) physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that your condition does not meet Medicare criteria 
for five (5) physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five (5) physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve five (5) physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, breast, unilateral, real time with image 
documentation, including axilla when performed; limited (CPT code 76642-26) provided on October 9, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your 
request. The Plan says this service was previously approved/paid. The Plan states there is no additional 
documentation supporting an additional study which was billed and remains denied. 
 
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 code 76642-26 is not supported in the medical record. The member had professional 
interpretation of a breast ultrasound on October 9, 2021. The submitted documentation supports 1 (one) unit of 
76642-26, which was previously approved/paid. There is no additional documentation supporting an additional 
study which was billed and remains denied. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; limited (CPT code 76642-26) provided on October 9, 
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel (81206, 81292, 81210, 81235, 81275, 81276, 81295, 81298, 81317, 81401, 81301, 81191, and 81309) provided on May 7, 2021.

You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the appropriate POS code.

The Plan must follow Medicare rules. Medicare rules say that 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 Tempus Gene Panel 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. Additionally, it is not appropriate to bill individual gene CPT codes, when either 5-50 or >50 gene panels are ordered. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel (81206, 81292, 81210, 81235, 81275, 81276, 81295, 81298, 81317, 81401, 81301, 81191, and 81309) provided on May 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve the 4 additional physical therapy visits. You say that the clinical notes 
provided support the need for the number of physical therapy visits being requested. The Plan denied your 
request. The Plan says the number of visits being requested are not medically necessary. 

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the 4 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy 
generally is not accepted as specific and effective therapy for the enrollee's condition beyond what was already 
approved by the health plan. The enrollee has had prior extensive therapy for this condition and the 
documentation does not reveal that the enrollee requires the unique skills of a professional therapist to safely 
and effectively provide treatment, or that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. The ongoing need for compression garment application 
does not require a skilled therapist. The enrollee has been approved additional therapy to transition to an 
independent home program. The enrollee can continue to follow-up with the wound care clinic. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 4 additional physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for travel allowance one way in connection with medically 
necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip 
charge (CPT code P9604) provided on February 4, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says they have insufficient documentation to corroborate the services so they cannot confirm 
Medicare coverage has been met. 

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of travel allowance one way in 
connection with medically necessary laboratory specimen collection drawn from home bound or nursing home 
bound patient; prorated trip charge (CPT code P9604) provided on February 4, 2021. have been met. 
Documentation was not provided to verify the services provided. Therefore, we decided that the Plan does not 
have to pay for travel allowance one way in connection with medically necessary laboratory specimen 
collection drawn from home bound or nursing home bound patient; prorated trip charge (CPT code P9604) 
provided on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 14, 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 submitted records do not support the billing of the -59 modifier. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our coder 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 these services Our reviewer says that the 
submitted records do not support the billing of the -59 modifier. Our coder reviewer found the operative report describes a portal vein reconstruction with a distal pancreatectomy and splenectomy. In this case, the more 
complex procedure (pancreatectomy and splenectomy) would be reported, and would include the portal vein 
reconstruction, since it is the less extensive procedure.The service was unbundled and the -59 modifier is not 
appropriate. 
 
We looked at this coder'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 pay for the surgical services rendered on April 14, 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. The Plan denied your request. The Plan says your rehab is not 
complex. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for surgical repair of a humerus fracture. You do not require 
treatment by multiple therapies in an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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.