Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that this is medically necessary. The Plan denied 
your request. The Plan says that you are able to perform all MRADLs independently with a rollator walker. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
a power scooter is not medically reasonable and necessary. The documentation does not support that you have 
a mobility limitation that significantly impairs your ability to participate in one or more mobility-related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary 
locations in the home. The documentation does not support that your mobility limitation cannot be sufficiently 
resolved by the use of a walker as the seating mobility evaluation notes that you are independent with your rollator and for MRADLs. The provider notes that you can walk a quarter mile. The documentation does not 
reveal that the power scooter will significantly improve MRADL participation in the home. Our physician 
reviewer found that your condition does not meet Medicare criteria for a power scooter. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
3, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic pain with long-term pain medication therapy. Definitive drug testing was 
performed. However, the records do not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results to justify this testing. Without 
sufficient support made in the provided documentation, this request for definitive testing will be considered not 
medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on November 3, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollees medical conditions is stable on outpatient medications with no issues 
that require a physicians evaluation three or more times per week. The enrollee does require physical therapy 
and occupational therapy services, but the medical records provided do not clarify why the enrollee requires an 
intensive inpatient rehabilitation therapy program. Provided records do not explain why the intensive inpatient 
rehabilitation therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing 
facility is not appropriate 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) admission 
from May 19, 2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that you would like your SNF care to continue 
to be covered. The Plan denied your request. The Plan says your inpatient stay has reached the 100-day benefit 
limit for this admission. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from October 12, 2021, to 
May 18, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve a continued skilled nursing facility (SNF) admission from May 19, 2022, 
forward.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the medical records provided support the need 
for SNF care. The Plan denied your request. The Plan says the documentation provided does not indicate that 
the enrollee has any daily skilled nursing needs. The Plan says that the enrollee's needs can be met at a lower 
level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing services. Records do not document the need for intravenous medications, new 
tube feeding, or ostomy care or daily complex wound care. The medical records do support that the enrollee 
requires skilled therapy services. Based on the medical records provided there is no documentation that daily 
skilled services are required. Although records document the enrollee is limited functionally, records document 
that further inpatient skilled therapy services are not indicated until her weight bearing status is upgraded by 
orthopedics. Based on the medical records provided there is no documentation that the enrollee requires the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services 
in the long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the records provided support the need for 
the requested device. The Plan denied your request. The Plan says there was not compelling rationale submitted 
that supported the use of a home mechanical ventilator to deliver assistance rather than a bilevel positive 
airway pressure (BiPAP) with a backup rate and average volume-assured pressure support (AVAPS) with auto-
EPAP (AE.) The Plan says that there is no documentation to suggest a BiPAP with back up rate and AVAPS 
with or without AE was utilized and failed. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator.  
 Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home 
ventilator is not medically necessary. The enrollee has chronic obstructive pulmonary disease (COPD)/asthma 
with moderate airways obstruction. Arterial Blood Gas (ABG) shows a normal PaCO2, so requirements for a 
respiratory assist device (other than continuation positive airway pressure) are not met. Medicare does not 
cover a home ventilator when used as bilevel positive airway pressure (BiPAP.) 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure fills a 
treatment gap for patients that do not receive adequate relief from traditional conservative methods and don't 
have instability to indicate fusion is the appropriate treatment. You say that the enrollee tried and failed 
conservative treatment without relief. You say that this procedure would improve the quality of life for the 
enrollee. The Plan denied your request. The Plan says there is little evidence in the medical literature to suggest 
that the requested procedure is appropriate to treat the enrollee's back pain. The Plan says that the requested 
procedure is not an accepted standard of medical practice for the enrollee's diagnosis. 
 
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 an Intracept procedure. Our reviewer 
says that an Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding Modic type changes at all of the 
requested procedure levels. The magnetic resonance imaging (MRI) did not demonstrate any Modic endplate 
changes at L4/5 disc level. Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. In this case, there are multiple plausible pathologic sources of significant 
pain generation. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OneTouch Ultra Test Strips for the enrollee. 
 
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are other preferred brands. 
 
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 test strips. Our reviewer says that 
the requested brand of test strips is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided, there is no documentation that there is a 
specific medical reason as to why the enrollee would need the requested brand of test strip as opposed to one of 
the health plan's preferred products.  
 
 
 
 
 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 test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the OneTouch Ultra Test Strips for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the ConfirmMDx test provided to the enrollee on December 23, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not show that the enrollee underwent a previous cancer-negative prostate 
biopsy within 24 months. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. The first 
transrectal ultrasound (TRUS) biopsy was on 12/23/21 with benign results. It showed a rising prostate-specific 
antigen (PSA) level. There was a negative digital rectal exam (DRE), and no fumarate hydratase (FH) prostate 
cancer. The ConfirmMDx test was provided to the enrollee on December 23, 2021. Based on the provided 
documentation, the records do show that the enrollee underwent a previous cancer-negative prostate biopsy 
within 24 months as required to meet criteria, and they meet all other criteria. Therefore, this request for 
ConfirmMDx will be considered medically necessary based on the provided documentation. 
 
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 been met. Therefore, we decided that the Plan has to pay for the 
ConfirmMDx test provided to the enrollee on December 23, 2021.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 12, 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. 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. For codes 81206, 81210, 
81235, 81272,81275,81276, 81292, 81301, 81311: The denial remains upheld as non-covered as Medicare 
denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code 
must be submitted for the panel. 
 
For codes 81191, 81317, 81321, 81295, 81298: remain 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 the On Campus Outpatient 
Hospital setting POS 22. Also, the laboratory results submitted indicate the specimen was collected on June 30, 
2021, and received by the lab on July 2, 2021; 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 laboratory services provided on July 12, 2021.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and does not require transfer to an LTACH. 
 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care facility.  
 The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (CPT code 99239) 
provided on June 10, 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 the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, CPT code 99239 remains 
not supported. The records submitted do not indicate a hospital discharge day management; more than 30 
minutes. Of note a discharge note indicating more than 30 minutes of time spent on discharge is required to 
support the billed code; therefore, the billed CPT code cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital discharge day management (CPT code 99239) provided on June 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided on 
January 29, 2022. 
 
You asked the Plan to pay for the abdominal ultrasound. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided on January 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on January 13, 2022. 
 
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your 
request. The Plan says this service cannot be billed by an audiologist. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will pay for evaluation and 
management (codes 99201 - 99499) services for specific non-physician practitioners (i.e., nurse practitioner 
(NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits 
them to bill these services. 
 
We looked at the file and Medicare rules. The evaluation and management service at issue was provided by an 
audiologist, who is not permitted to bill this service under Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an office visit (99213) provided on January 13, 2022.