Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 18, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says it was not medically necessary for the enrollee's 
treatment on this date to be provided in an inpatient setting; treatment at the outpatient observation level would 
have been appropriate. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee presented to the emergency department (ED) on May 18, 2021, for 
evaluation after an episode of slumping over the dinner table and suddenly stopping responding. Emergency 
medical services evaluated her at home with stable vital signs, blood sugar of 90, and non-verbal. She was 
transported to the emergency department and upon arrival, she was able to speak her name and move all 
extremities; however, she seemed globally weak with possible subtle facial droop. Labs and imaging were 
unremarkable, electrocardiogram showed no significant change from previous study, and blood pressure was 
elevated. After treatment in the emergency room, she was markedly improved with normalization of blood 
pressure and speaking and acting normally according to her family. She was then admitted to the hospital on 
May 18, 2021, and was discharged home later that day after a stroke was ruled out. The review has determined 
that the record did not show that at the time of inpatient admission, the admitting physician reasonably 
expected that the enrollee necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low dose computed tomography (CT) scan of the lungs 
for lung cancer screening for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met. 
 
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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the criteria would 
otherwise be met except for the fact that the enrollee quit smoking 30 years ago. The criteria specify a patient 
must either still be smoking or having quit within the past 15 years. For this reason, the NCD criteria are not 
met. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve low dose computed tomography (CT) scan of the lungs for lung cancer screening for the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001). 
 
You asked the Plan to pre-approve a standard wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there is no documentation of a formal functional evaluation of the 
member provided that indicates that she has (or will have after surgery) a mobility limitation which cannot be 
sufficiently resolved using an appropriately fitted cane or walker. Nor is there documentation that she can 
safely self- propel a manual wheelchair. There is no documentation that a caregiver is available, willing and 
able to provide assistance with the wheelchair in case the member is unable to self-propel a manual wheelchair. 
There is also no documentation of a formal evaluation of the members home that indicates there is adequate 
access between rooms, maneuvering space, and surfaces for use of a manual wheelchair. 
 
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.  
 
The file does not indicate that the member has a mobility deficit that impairs their participation in MRADLs, 
their condition cannot be improved by a walker, cane or manual wheelchair, they can safely operate the PMD 
being requested, or an evaluation of the members home. This means that Medicare rules for coverage of a 
wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard 
wheelchair (K0001).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 6, 2022. 
 
You asked the Plan to pre-approve SNF care after April 6, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a 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 SNF care after April 6, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a 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 after April 6, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after April 6, 2022.
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 the enrollee is set to be discharged from the hospital 
but has no safe discharge place. The Plan denied your request. The Plan says the denial of authorization for 
SNF care is correct. 
 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 the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor sensor kit 
(K0553) provided on October 29, 2021. 
 
You asked the Plan to pay for a Freestyle Libre sensor kit. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for continuous 
glucose monitors and related supplies 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 require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre sensor kit have not been met. 
Therefore, we decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor 
sensor kit (K0553) provided on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift. 
 
You asked the Plan to pre-approve a seat lift. You say that you need assistance to stand up from the chair. The 
Plan denied your request. The Plan says you would not be independent with a seat lift. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We looked at the file, and Medicare rules. The medical records provided do not show that you have severe 
arthritis or a severe neuromuscular disease. The records do not show that you are completely unable to stand up 
from a regular armchair. Based on this information, we decided that Medicare rules for coverage of a seat lift 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 21196 and 40848 billed for date of service 
June 14, 2021. 
 
You asked the Plan to pay for procedure codes 21196 and 40848. You say that you have provided medical 
records to support payment of these codes. The Plan denied your request. The Plan says procedure code 21196 
is not supported in the medical record and procedure code 40848 is inclusive to code 15757 which was already 
paid. 
 
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 21196 is Reconstruction of mandibular rami and/or body, 
sagittal split; with internal rigid fixation. 
 
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 procedure codes 21196 and 40848. Our reviewer says that these two codes are not supported in the medical record. Our reviewer found for procedure code 21196, the 
operative report does not include documentation of reconstruction of mandibular rami and/or body, sagittal 
split; with internal rigid fixation.  To cite the operative report: We then turned our attention to the open 
mandibular reduction and closure of the labiomandibulotomy. This was after the vast majority of the flap inset 
had been successfully performed as described above with the exception of the anterior most aspect. The 
mandibular segments were reduced in the anatomical position with the assistance of mandibular reduction 
forceps. The outer cortex of the mandible was burred to allow for a flap plate setting. A 2.5 mm titanium plate 
was contoured following the defect and subsequently secured with bicortical screws with 3 screws placed on 
each side of the osteotomy site. A second 1.0 mm titanium plate was utilized to increase the stability of the 
fixation. This was secured with 8 mm monocortical screws with 2 screws on each side of the osteotomy 
site."  There is a more appropriate code to report for procedure documented. In relation to code 40845, 
although, there is no NCCI edit for codes 40845 and 15757, the free skin graft was performed as part of the 
complex vestibuloplasty.  Therefore, the highest dollar value code is listed as the primary procedure and 
subsequent procedure would be appended with modifier 51.   
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 21196 and 40848 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 21196 and 40848 billed for date of service June 14, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the item is medically necessary. The Plan 
denied your request. The Plan says convenience items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (CPT code 00410) provided on November 16, 
2021. 
 
You asked the Plan to pay for the anesthesia. You say that the procedure billed was the correct procedure. 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. 
 
The documentation does not indicate whether the patient was registered as inpatient or outpatient. The claim 
was billed with an inappropriate place of service 22 (outpatient). According to claims history, the patient was 
inpatient during this date of service from November 12, 2021, through November 17, 2021, billed with TOB 
111 for inpatient. Based on this information, we decided that Medicare rules for coverage of the anesthesia 
have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia (CPT code 
00410) provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for infrared light therapy provided to the enrollee on December 8, 
2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this type of therapy is not covered by Medicare when rendered by a licensed 
acupuncturist. 
 
The Plan must follow Medicare rules. The rules say that for services provided on or after January 21, 2020, 
Medicare offers limited coverage for acupuncture treatments for chronic low back pain only with no more than 
20 sessions per year. However, your Plan offers some coverage beyond the Medicare acupuncture benefit. As 
such, the Plans rules apply in this case. While the Plan covers acupuncture, the Plan does not cover infrared 
therapy in an acupuncture setting. Therefore, we decided that the Plan does not have to pay for infrared light 
therapy provided to the enrollee on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 14, 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. CPT code(s): 81292, 
81206: The rules say that if one laboratory procedure evaluates multiple genes using a next generation 
sequencing 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 CPT code. If no CPT code accurately describes the procedure performed, the laboratory 
may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report 
multiple individual CPT codes describing the component test results when medically reasonable and necessary. 
Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) 
and ordered by the physician who is treating the beneficiary and using the results in the management of the 
beneficiary's specific medical problem. You can find this information in Chapter X: Pathology/Laboratory 
Services (CPT codes 80000-8999) for National Correct Coding Initiative Policy Manual for Medicare Services. 
 
CPT code(s): 81309, 81194, 81235, 81317, 81301, 81298, 81295, 81276, 81275, 81210, 81401, 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 an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on May 21, 2021 and received by the lab on May 22, 2021. Of note, the patient resides 
in Louisiana and the billing laboratory is located in Illinois; 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 June 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee was told she had poor bone quality by her 
surgeon and her risk of hip fracture in the next 10 years is 3%. You say that this level of risk meets criteria to 
treat osteoporosis and the proposed treatment with Prolia is medically necessary. The Plan denied your request. 
The Plan says the use of Prolia requires documentation supporting the diagnosis of osteoporosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Prolia. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear (CPT code 85060) provided on October 13, 
2021. 
 You asked the Plan to pay for the blood smear. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the blood smear have not been met. CPT code 85060 has a 
Professional Component (PC)/Technical Component (PC/TC) indicator of 8 per the Physician Fee Schedule 
Search. CPT code 85060 may not be paid if furnished to hospital outpatients or non-hospital patients. The 
enrollee was outpatient at a hospital on October 13, 2021. The denied CPT code 85060 may not be paid if 
furnished to hospital outpatients or non-hospital patients. Review of the enrollee's claim shows the provider 
billed in a place of service of 22- Outpatient Hospital. If the provider determines that a billing error occurred 
during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to 
consider services for payment. Therefore, we decided that the Plan does not have to pay for the blood smear 
(CPT code 85060) provided on October 13, 2021.