Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that this will help the enrollee to improve his function 
and to regain strength. The Plan denied your request. The Plan says that this enrollee does not meet medical 
necessity and criteria for requested skilled nursing facility 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 care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 
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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stab phlebectomy procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has saphenous reflux. 
 
The Plan follows Medicare rules. Medicare rules say that varicose vein treatment is only covered under certain 
medical indications.  
 
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 for stab phlebectomy to be covered, there have to be symptoms the persist despite 
conservative treatment six weeks after the saphenous reflux has been treated. The ablation portion of the 
procedure has already been approved. This has not yet been performed. The Plan does not provide for 
simultaneous tributary treatment at the time of saphenous treatment; a rationale for this is that many patients 
will experience satisfactory relief of symptoms with saphenous treatment alone. Therefore, the request is not 
medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a stab phlebectomy procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says an epidural steroid injection does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
there is no recent documentation of a physical exam demonstrating motor, sensory, or reflex abnormality. The 
lack of physical exam documentation does not meet the LCD criteria.  Therefore, at this point, the request is 
deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305) provided on June 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim was filed on time. The Plan denied your 
request. The Plan says this claim was not filed on time. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until June 30, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services (88305) provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
June 13, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date of service June 13, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional 16 fractions of intensity-modulated radiation therapy 
(IMRT). 
 
You asked the Plan to pre-approve an additional 16 fractions of IMRT. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an additional 16 fractions of (IMRT). 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found that while there is evidence that moderate hypofractionation (larger 
radiation doses per session in fewer sessions) offers similar outcomes to conventional fractionation, 44 total 
fractions are considered acceptable by guidelines and would be within accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 16 fractions of (IMRT) have been met. Therefore, we decided that 
the Plan has to pre-approve an additional 16 fractions of intensity-modulated radiation therapy (IMRT).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the records provided support the 
need for the request item. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483, 80307) provided on February 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the record. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab 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 lab services (G0483, 80307) provided on February 21, 2022.
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 you were admitted for coronary artery bypass grafting complicated by anemia, sepsis, 
and ICU psychosis. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77067 billed for date of service June 14, 
2022. 
 
You asked the Plan to pay for procedure code 77067. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77067 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 77067 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77067 billed for date of service June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 25, 2022, billed with 
codes 81235, 81206, 81210 and 81275. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 25, 2022, billed with codes 81235, 81206, 81210 and 81275.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 94761. You say that this code was billed appropriately. The Plan 
denied your request. The Plan says payment for code 94761 is bundled into payment for code 99204. 
 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 94761 
is a column II code to column I code 99204. 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 procedure code 94761 billed for date of service April 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy (15830). 
 
You asked the Plan to pre-approve a panniculectomy. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the request 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 a panniculectomy. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the record provided does not demonstrate the presence of chronic intertrigo that either 
consistently recurs over 3 months while receiving appropriate medical therapy or remains refractory to 
appropriate medical therapy over a period of 3 months. 
 
 
  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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy (15830).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on November 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab 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 lab services (G0482) provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) provided 
from November 22, 2021, to December 15, 2021. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used in the treatment of 
peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Per LCD L33829, the requested PCD coded E0675 is not medically 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the PCD 
have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression 
device (PCD) (E0675) provided from November 22, 2021, to December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). You asked the Plan to pre-approve injections. You say that this would be a preferred method of treatment over 
surgical intervention as the enrollee would be a poor surgical candidate based on age and medical 
comorbidities. The Plan denied your request. The Plan says the enrollee does meet medical necessity and 
criteria for requested repeat ESI based on not having 50% or greater pain relief for at least 3 months. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a repeat epidural injection can be considered when the medical record documents at least 50% 
of sustained improvement in pain relief and/or improvement in function measured from baseline using same 
scale for at least three months. The documentation does not reveal that the enrollee has had 50% sustained 
improvement in pain and/or function for at least 3 months from prior injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for approved shoulder 
surgery. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says the enrollee 
will not require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient services. Our physician 
reviewer found that the enrollee has a history of back and leg pain. He has been approved for a decompression 
laminectomy and left hemi-laminectomy. There are no noted respiratory or cardiovascular symptoms noted. 
The records do not indicate the enrollee has a condition that would require an inpatient admission of greater 
than two midnights. Therefore, the requested inpatient 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 inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient hospital services for approved shoulder surgery.