Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on October 1, 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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 subsequent hospital care rendered on October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 rendered on February 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve PT visits. You say that you have pelvic pain. You also say that you feel this 
is medically necessary. The Plan denied your request. The Plan says the provided documentation does not 
indicate that the services are 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 PT 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 you have had prior therapy and the documentation does not reveal that you 
require 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. The 
reviewer found that 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 your current condition or to prevent or slow further deterioration. The reviewer found that you have 
been instructed in an independent home program. Therefore, the reviewer found that ongoing skilled therapy is 
not 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 PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 9 physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says medical necessity rules for SNF care have not been met. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee is medically stable and can 
receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be 
appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) admission and 
services from May 18, 2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that services are medically necessary because 
you are not yet able to use a walker. The Plan denied your request. The Plan says you no longer require skilled 
services and the continuation of SNF is not medically necessary. 
 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 continued SNF care from May 18, 
2022, forward. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 
that you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) admission and services from May 18, 
2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adhesive bandages rendered on November 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of N represents a non-covered 
service. 
 
We looked at the file and Medicare rules. Billed procedure code A6413 (adhesive bandage, first aid type, any 
size) has a status indicator of N and is non-covered by Medicare. Therefore, we decided that the Plan does not 
have to pay for the adhesive bandages rendered on November 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits in your home (G0299 x 9). 
 
You asked the Plan to pre-approve home health visits. You say that the requested visits are medically 
necessary. The Plan denied your request. The Plan says the requested visits were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health visits. Our reviewer says 
that the requested home health visits are not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The reviewer found that the enrollee does not require additional skilled 
nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, perform a maintenance program to maintain their condition and/or prevent deterioration. The 
reviewer found that the enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. Therefore, the reviewer found that the requested home health visits are not 
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 home health visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing visits in your home (G0299 x 9).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on February 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable.  
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 the computed tomography (CT) scan of the head/brain rendered 
on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of short arm splint (forearm to hand) (29125) 
provided October 19, 2021. 
 
You asked the Plan to pay for the emergency services. You say that the claim has not been paid in full under 
the terms of the contract for the services provided. The Plan denied your request. The Plan says medical 
necessity cannot be established for the provided services. Missing or invalid diagnosis code. 
 
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 application of short arm splint 
(forearm to hand) (29125) provided October 19, 2021. have been met. medical records were needed to support 
medical necessity of the services. The Plan made several attempts to obtain the additional information without 
success. Therefore, we decided that the Plan does not have to pay for application of short arm splint (forearm to 
hand) (29125) provided October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pancreas transplant (48554). 
 
You asked the Plan to pre-approve a pancreas transplant. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the requested procedure does not meet criteria. 
 
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 a pancreas transplant. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 35-year-old female with diabetic nephropathy and with an approved 
kidney transplant. A request for pancreas transplant was made. A1C 12% on previous records. However, there 
is no documentation of difficulty to control diabetes, failure, or contraindication to standard diabetes treatments 
to justify this request. There is documentation of significant diabetes medication non-compliance including 
avoiding prescribed insulin. Therefore, without sufficient support made for this request, the pancreas transplant 
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 a pancreas transplant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pancreas transplant (48554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on July 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 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 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 mass spectrometry rendered on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says that the enrollee does 
not meet Medicare criteria for coverage. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's medical, nursing and therapy needs justified in the clinical 
documentation warrants an acute inpatient hospital stay focused on rehabilitation. Per evaluating therapists the 
enrollee requires ongoing speech, occupational and physical therapy with an interdisciplinary approach to care. 
Intense therapy is specifically recommended by the evaluating therapist along with the expectation that the 
enrollee will be able to fully participate and benefit from an intensive rehabilitation program. Rehabilitation 
recommends that the enrollee receive at least 3hrs of therapy per day, 5 days per week and close medical 
monitoring. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
 
 
 
 
 
 
 
 
 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: 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 is medically necessary. The 
Plan denied your request. The Plan says that an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found while the enrollee has documented medical conditions and complications that 
would benefit from close medical monitoring and skilled nursing, the evaluating therapists (both physical and 
occupational therapy) specifically document that enrollee would not be able to tolerate or benefit from intense 
therapy. The documentation indicates that the enrollee's primary care team also documents that patient would 
not tolerate intense therapy. Therefore, the reviewer found that the IRF admission is not 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan, thorax (71250). 
 
You asked the Plan to pre-approve a CT scan, thorax. You say that a CT scan is medically necessary. The Plan 
denied your request. The Plan says that a CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only 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 pre-approve a CT scan, thorax. Our reviewer says 
that a CT scan, thorax is medically necessary. Our physician reviewer found that the enrollee has severe asthma 
and is on maximum and appropriate medication. The pulmonary function test is very abnormal. A CT of the 
chest to evaluate the degree of air trapping and residual infiltrate, etc. is very reasonable and should be 
approved. 
 
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 CT scan, thorax have been met. Therefore, we decided that the Plan has to 
pre-approve a CT scan, thorax (71250).  
 
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 lab services provided on December 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no evidence to 
support the referring provider was treating the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records do not show that the lab services in question were 
ordered by the enrollee's treating physician. 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 the lab 
services provided on December 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (23412, 23430, and 23020) 
provided on August 12, 2021. 
 
You asked the Plan to pay for surgical assistant services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the codes billed are not supported. 
 
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.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, no records were submitted to support that codes 23412, 23430, and 23020 represent 
distinct procedural services. Based on this information, we decided that Medicare rules for coverage of services 
billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services (23412, 23430, and 23020) provided on August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Zip Lumbar Fusion procedure. 
 
You asked the Plan to pre-approve the Aurora Zip Lumbar Fusion procedure. The Plan denied your request. 
The Plan says the Aurora Zip Lumbar Fusion procedure 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 Aurora Zip Lumbar Fusion 
procedure. Our reviewer says that the Aurora Zip Lumbar Fusion procedure is not considered medically 
reasonable and necessary. Our physician reviewer found the Aurora Zip Lumbar Fusion surgery is 
experimental. More research is needed. 
 
 
 
 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 Aurora Zip Lumbar Fusion procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Aurora Zip Lumbar Fusion procedure.