Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive sacroiliac (SI) joint fusion 
(27279). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee's ongoing symptoms 
despite conservative treatment including diagnostic injections and positive physical exam findings, the enrollee 
is a candidate for a left sacroiliac joint fusion. The Plan denied your request. The Plan says the enrollee does 
not meet the coverage criteria for minimally invasive sacroiliac joint fusion. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented SI joint instability, fracture, or lesion. There are no x-rays 
showing normal hip joints. There are no imaging studies showing SI joint disease. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the minimally invasive sacroiliac (SI) joint fusion (27279).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 2, 2022, 
through May 5, 2022, at the Diagnosis Related Group (DRG) 435 originally billed. 
 You asked the Plan to pay for the acute inpatient hospital care billed at DRG 435. You say that you are 
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says there 
was insufficient clinical evidence to support the diagnosis of a biliary obstruction. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code K83.1 as defined by obstruction of a 
bile duct. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care 
billed at DRG 435. Our reviewer says that the acute inpatient hospital care provided was not billed correctly. 
Our physician reviewer found that the enrollee was treated in the hospital. He presented with elevated bilirubin, 
transaminitis in the setting of intrahepatic bile duct carcinoma (cholangiocarcinoma) status post an endoscopic 
retrograde cholangiopancreatography (ERCP) stent in the past. He was undergoing chemotherapy and had a 
cholecystostomy tube in place. The ultrasound of the abdomen revealed no ductal dilation. He was 
asymptomatic throughout the hospitalization and his liver enzymes trended down with conservative treatments. 
There was no documentation of intervention performed for a bile duct blockage, nor was there imaging or other 
objective evidence for a bile blockage to support the diagnosis of an obstruction of a bile duct. Therefore, the 
DRG 436 would be more appropriate for this admission based upon the documentation provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the acute inpatient hospital care provided from May 2, 2022, through May 5, 2022, at the Diagnosis Related 
Group (DRG) 435 originally billed.
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 enrollee is expected to make reasonable progress 
from and actively participate in an intensive rehabilitation program that requires medical/physician oversight 
for ongoing clinical conditions and active co-morbidities. The Plan denied your request. The Plan says the 
enrollee records do not meet all the required criteria for admission to an Inpatient Rehabilitation Facility. 
Skilled therapies at home or at a skilled nursing facility may be approved upon request. 
 
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 there is not a reasonable expectation that the enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ajovy. 
 
You asked the Plan to pre-approve Ajovy. The Plan denied your request. The Plan says Ajovy is on the self-
administered drug list and is excluded from coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ajovy.  
 
  Benefits for Ajovy may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immediate maxillary partial denture. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
immediate maxillary partial denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's medical condition and treatments, will not need LTACH level of service for 25 or more days, these 
needs can be safely met with services in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH 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 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 pay for the lab services provided on January 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that it was not the provider's fault that the claims were 
not filed timely. The Plan denied your request. The Plan says this claim was not filed timely. 
 
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 August 12, 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 provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service September 
29, 2022. 
 You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 99153. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 99153. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99153 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99153 billed for date of service September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a GeneSight gene panel. 
 
You asked the Plan to pre-approve a GeneSight gene panel. You say that the medical records provided support 
that the GeneSight testing will provide guidance to better assist you with your treatment needs. The Plan denied 
your request. The Plan says the records do not show what medications are being considered.  
The Plan follows Medicare rules. Medicare rules say that PGx tests are indicated when medications are being 
considered for use and are known to have a gene(s)-drug interaction that has been demonstrated to be clinically 
actionable as defined by the FDA or CPIC guidelines. 
 
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 GeneSight gene panel. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of 
bipolar II disorder, panic, and generalized anxiety disorders. The appeal included information from your 
psychiatric advanced practice nurse practitioner. These notes described a history of electroconvulsive therapy 
(ECT) treatment in 2000 and describes the current prescriptions of lorazepam, trazodone, and citalopram. There 
are no records describing intent to change your medications to ones that have known gene-drug interactions. 
The clinical record does not clearly show the use of or intent to prescribe a drug that has known drug-gene 
interactions which is required for a PGx test to be considered medically necessary with the purpose to define 
the safe use of that drug in that patient. 
 
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 GeneSight gene panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a GeneSight gene panel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87998 billed for date of 
service May 3, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87998. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 87998 is 
bundled into payment for code 87801. 
 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 codes 
87481, 87653, and 87998 are column II codes to column I code 87801. 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 codes 87481, 87653, and 87998 
billed for date of service May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and determination of refractive state 
(92015) provided on October 22, 2022. 
 
You asked the Plan to pay for the vision services. You say that your primary care physician referred you for the 
eye exam. The Plan denied your request. The Plan says the non-routine vision service is not covered for this 
diagnosis. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when The Plan covers these services when they are routine in nature. 
 
We looked at the file and the Plan's rules. The Plan covers routine vision care. Based on this information, we 
decided that the Plan's rules for coverage of the vision services have not been met. Specifically, the file 
indicates that the exam in this case was medical in nature. Therefore, we decided that the Plan does not have to 
pay for the office visit (99213) and determination of refractive state (92015) provided on October 22, 2022.  
 
Please note: The Plan should process procedure code 99213 under the enrollees medical benefit. Also, 
procedure code 92015 would not be covered under the medical benefit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve additional home health skilled nursing visits. You say that the medical 
records provided support the need for the requested skilled nursing visits. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health skilled nursing 
visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer 
found the enrollee does not have documented skilled nursing needs. Oral medication is not a skilled need. Daily 
medication is not intermittent. The requested home health skilled services are not medically necessary or 
reasonable. 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 home health skilled nursing visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing (U0004, U0005, G2023) provided on 
July 26, 2022. 
 
You asked the Plan to pay for the COVID-19 testing. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing is not covered by the Plan because the enrollee was enrolled in 
hospice at the time the services were provided. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the COVID-19 testing (U0004, U0005, G2023) provided on 
July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed for date of service September 16, 
2022. 
 
You asked the Plan to pay for the billed service. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the coding criteria. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested.  Based on this information, we decided that Medicare rules for coverage of the 
billed service have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
billed for date of service September 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial 
of admission to an IRF. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the clinical documentation shows that the enrollee has active medical 
comorbidities however, the documentation does not specify any complex functional impairments. Thus, the 
complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be expected to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, single-photon emission 
computerized tomography (SPECT) scan (78452). 
 
You asked the Plan to pre-approve a SPECT scan. You say that you want to have this test done so you can feel 
at peace since you have no one taking care of you. The Plan denied your request. The Plan says there is no 
indication that you would not be able to have an exercise treadmill test done or that it would be unreliable or 
inconclusive. 
 
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 SPECT scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the electrocardiogram (ECG) shows an uninterpretable pattern. 
There is no evidence provided that would support the need for radionuclide stress testing. Our reviewer also 
found that there is insufficient documentation to support the medical necessity for the requested cardiac stress 
testing in your clinical management. 
 
 
 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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a myocardial perfusion imaging, single-photon emission computerized tomography 
(SPECT) scan (78452).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on September 16, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and was reported correctly. 
The Plan denied your request. The Plan says that the code reported for these services is not supported in the 
medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s), if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records support that 19 drug 
classes were tested in this case, including amphetamines, benzodiazepines, buprenorphine, cannabinoids 
(natural), cocaine, fentanyls, gabapentin (non-blood), heroin metabolite, methadone, 
methylenedioxyamphetamines, methylphenidate, opiates, opioids and opiate analogs, oxycodone, 
phencyclidine, pregabalin, skeletal muscle relaxants, tapentadol and tramadol. Based on this information, we 
decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan 
has to pay for definitive drug testing (G0482) provided on September 16, 2022.  
 
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.