Persius/hicric huggingface dataset:
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 LTACH services. You say that LTACH is medically necessary as the 
enrollee has a long-complicated hospital course ahead of him. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient care at the current hospital and LTACH would offer no additional 
services. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JAK2 V617F genetic mutation testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that JAK2 V617F testing is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has had erythrocytosis for 
several years. On March 9, 2022 his hemoglobin was 15.0 and hematocrit was 46.8 percent. The clinical 
documentation does not support that the enrollee is BCR-ABL negative and JAK2-negative, and has clinical, 
laboratory, or pathological findings suggesting myeloproliferative neoplasm, polycythemia vera, essential 
thrombocythemia, or primary myelofibrosis, or a myelodysplastic syndrome. The testing is therefore not 
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve JAK2 V617F genetic mutation testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight testing provided to the enrollee on December 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this testing has not shown to be useful or appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of 
GeneSight testing.  
 
Medicare does not currently consider the denied testing to be reasonable or necessary. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. 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 GeneSight testing provided to the enrollee on December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on June 
1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed/supported. 
 
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 the denied codes were: 
 
CPT 72129: 
 
Computed tomography, thoracic spine; with contrast material 
 
CPT 72132: 
 
Computed tomography, lumbar spine; with contrast material 
 
CPT 74177: 
 
Computed tomography, abdomen and pelvis; with contrast material(s) 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found while there are two reports of each 
exam in the submitted records, those reports are duplicated. The enrollee only had one of each exam in 
question on 6/1/21. 
 
We looked at this coder'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 additional imaging services provided to the enrollee on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450), provided on 
August 19, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the service should be covered. The Plan denied your 
request. The Plan says the records submitted do not indicate that two separate services were provided. 
 
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 the computed tomography (CT) scan 
(70450), provided on August 19, 2021. have been met. Specifically, there is no evidence that a second scan was 
done on this date of service. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan (70450), provided on August 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Orthovisc or Supartz FX. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our physician reviewer found 
that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The Plan requires a trial 
of Orthovisc or Supartz FX before they will approve the requested drug. The records do not indicate that she 
has tried and failed the plan's preferred step one alternative. The record does not indicate that she has a 
contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation discharge services provided on September 
19, 2021, billed with code 99217. 
 
You asked the Plan to pay for the observation discharge services. You say that this was correctly billed and 
should not be considered inclusive to any other charges. The Plan denied your request. The Plan says the 
enrollee was not discharged on this date. The enrollee remained in the hospital until September 23, 2021. 
 
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 99217 is Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.])  
We find that CPT code 99217 is not supported in the medical record. Specifically, the documentation does not 
support that the enrollee was discharged on the date of service at issue. The progress note indicates that 
discharge was planned, but that the enrollee then had a syncopal episode and remained in the hospital. Based 
on this information, we decided that Medicare rules for coverage of the observation discharge services have not 
been met. Therefore, we decided that the Plan does not have to pay for the observation discharge services 
provided on September 19, 2021, billed with code 99217.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
November 24, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says the 
Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent 
care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) services. 
 
You asked the Plan to pre-approve additional PT services. The Plan denied your request. The Plan says the 
requested service is 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 additional PT services. 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 patients condition. Our reviewer found that the patient has had prior 
therapy and the documentation does not reveal that the patient requires the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist beyond what was approved already. 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 patient'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 additional PT services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy (PT) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 25, 2021.  
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on July 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 24, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on December 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on August 29, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not 
coded appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable results, only a single procedure code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic panel testing provided on August 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (95250). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee is on diabetic 
medication which increased from 500 mg twice a day to 1200 mg daily. You also say the enrollee needs to 
check her glucose. The Plan denied your request. The Plan says the enrollee is not on insulin; therefore, the 
requested device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (95250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod 5 G6 kit, disposable insulin pump system. 
 
You asked the Plan to pre-approve Omnipod 5 G6 kit. You say that you need this device to monitor your type 1 
diabetes. The Plan denied your request. The Plan says disposable drug delivery systems are non-covered 
devices because they do not meet the Medicare definition of durable medical equipment. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say disposable drug delivery systems are non-covered 
devices because they do not meet the Medicare definition of durable medical equipment. 
 
We looked at the file and Medicare rules. The documentation indicates that the requested pump system is not a 
covered benefit with your Part B Plan as they are disposable and not considered durable medical equipment.  
Based on this information, we decided that Medicare rules for coverage of Omnipod 5 G6 kit have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an Omnipod 5 G6 kit, disposable insulin 
pump system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee still needs skilled nursing 
services and daily therapy. The Plan denied your request. The Plan says you have exhausted your 100-day 
benefit allowance for skilled nursing facility care for this benefit period. 
 
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 November 11, 2021, to 
March 21, 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 continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level of facet joint injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered under certain 
medical indications.  
 
The file shows that three levels of injections were requested. The Plan has agreed to pre-approve 2 levels. 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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She has pain in the right lower back that radiates to 
the right gluteal area and down the right leg.  The pain increases with activity, sitting, bending, and walking.  
She has been treated with medical therapy including, narcotics, physical therapy, a home exercise program, 
chiropractic care, and injections. According to the coverage criteria, facet joint injections are indicated when 
there is absence of untreated radiculopathy or neurogenic claudication. In this case, the enrollee has 
radiculopathy. Of note, for facet joint interventions, one to two levels, either unilateral or bilateral, are allowed 
per session per spine region. The review also determined that there was insufficient documentation to show that 
a third level would be 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a third level of facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus gene panel testing provided to the enrollee on 
September 3, 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 the use of multiple CPT codes, instead of a single panel CPT code is not supported. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Tempus gene panel testing provided to the enrollee on September 3, 2021.