Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO) provided to the enrollee on 
June 8, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the medical records indicate that there is pain, but do not indicate the location of the 
pain. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesnt support that the enrollee has had an injury or surgery that 
would necessitate a spinal orthosis. There is no documentation to support that the enrollee was having 
significant pain that would require restricting mobility of the trunk or that the enrollee has weak or deformed 
spine or spinal muscles. The requested spinal orthosis 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a lumbar-sacral orthosis (LSO) provided to the enrollee on June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 26, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. 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. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. No TC 
billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, 
generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT code 85060 
furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare 
rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) 85060 billed for date of service August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (T4535, T4526). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are necessary. The Plan 
denied your request. The Plan says the requested items are disposable. Therefore, coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that DME is defined as equipment which can 
withstand repeated use. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of incontinence supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve incontinence supplies (T4535, T4526).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 services was not filed until May 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 services provided on May 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revascularization services (CPT code(s): 37221, 
37224, 37225, 37226, 37227, 37228, 37229, 37230 and 37231). 
 
You asked the Plan to pre-approve the revascularization services. You say that the services are necessary. The 
Plan denied your request. The Plan says the services are not 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 revascularization services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient documentation to support the medical necessity for 
percutaneous transluminal angioplasty (PTA) with stent placement in this enrollees 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 the revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the revascularization services (CPT code(s): 37221, 37224, 37225, 37226, 
37227, 37228, 37229, 37230 and 37231).
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 you are requesting a reconsideration for IRF denial 
due to enrollee being at high risk for infection in the hospital. The Plan denied your request. The Plan says the 
enrollee does not meet the approval requirements for IRF services. 
 
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 enrollee does not require treatment by multiple therapies or an intensive 
rehabilitation therapy program. While the medical record supports the member's continued need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement, there is no documented need 
for intensive rehabilitation services. Medically necessary care can be provided in a different level of 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 inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee will benefit from intensive skilled 
therapy to progress back to their prior level of function. The Plan denied your request. The Plan says that the 
admission to an IRF 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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. Currently, the enrollee is weight bearing as 
tolerated. The enrollee has had a decline from their baseline level of function and would likely benefit from 
therapy, but they do not require the intensity of therapies provided at an acute inpatient rehabilitation 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 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: Favorable

 
We decided that the Plan has to pay for the positron emission tomography (PET) of the skull base to mid-thigh 
(78815), low osmolar contrast material (Q9967), and Piflufolastat (A9595) provided on March 9, 2022. 
 
You asked the Plan to pay for the PET scan, low osmolar contrast material, and Piflufolastat. You say that you 
believe these services were appropriate based on the enrollee's past medical history. The Plan denied your 
request. The Plan says that these services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the PET scan, low osmolar contrast material, 
and Piflufolastat. Our reviewer says that this service is reasonable and medically necessary. Our physician 
reviewer found a prostate-specific membrane antigen (PSMA) PET scan is an acceptable alternative to bone 
scans for an enrollee with metastatic prostate cancer. In addition, it is necessary to determine eligibility for 
certain treatments. Our reviewer also found that a PSMA PET scan is now a standard of care in metastatic 
prostate cancer. 
 
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 PET scan, low osmolar contrast material, and Piflufolastat have been met. 
Therefore, we decided that the Plan has to pay for the positron emission tomography (PET) of the skull base to 
mid-thigh (78815), low osmolar contrast material (Q9967), and Piflufolastat (A9595) provided on March 9, 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to no longer require acute care services as they are already at 
a lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology, concentration technique, smears and 
interpretation (88108) provided June 6, 2022. 
 
You asked the Plan to pay for the cytopathology procedures. You say that please see attached medical records 
showing medical necessity. Please reconsider the claim. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. 
 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 cytopathology, concentration technique, smears and 
interpretation (88108) provided June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration of the 
denied admission to a LTACH based on the records that were submitted. The Plan denied your request. The 
Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving but somewhat unstable and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins (93971) provided on 
November 16, 2021. 
 
You asked the Plan to pay for the duplex scan of extremity veins. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says this service does not meet the 
requirements for coverage. 
 
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 93971 is duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study. 
 
 
 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the duplex scan of extremity veins. Our reviewer says that 
the service remains denied per Centers for Medicare and Medicaid Services guidelines. Our reviewer found the 
stated reason for the exam does not include a codable ICD-10 designation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the extremity study have not been met. Therefore, we decided that the Plan does 
not have to pay for the duplex scan of extremity veins (93971) provided on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
16, 2022, to March 9, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you believe these services were 
medically necessary and the medical records do support the use. The Plan denied your request. The Plan says 
pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided February 16, 2022, to March 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 01936 billed for date of service November 3, 2021. 
 
You asked the Plan to pay for code 01936. You say that this service is separately payable. The Plan denied 
your request. The Plan says that anesthesia services are considered incidental to the procedure performed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has failed to provide any citation, rule, explanation, or 
analysis of its denial.  There is no information in the limited case file the Plan submitted to us explaining what 
code, exactly, the denied anesthesia services are supposed to be a component of. The Plan failed to provide any 
claim information at all.  The burden is on the Plan to prove that its denial is correct, and they have failed to do 
so in this case because of the significant lacking documentation in the case file submitted to us. Therefore, we 
decided that the Plan has to pay for code 01936 billed for date of service November 3, 2021.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is presently receiving appropriate services in the acute care setting. 
Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower 
level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility, or 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx testing (0037U) provided on April 25, 
2022. 
 
You asked the Plan to pay for FoundationOne CDx testing. You say that this is an FDA approved test which 
was medically necessary. The Plan denied your request. The Plan says under Medicare guidelines, your request 
is not medically necessary because your records do not show either recurrent, relapsed, refractory, metastatic, 
or advanced stage III or IV cancer or that you have decided to seek further treatment. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare covers this NGS testing when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and has not been 
previously tested with the same test using NGS for the same cancer genetic content. 
 
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 FoundationOne CDx testing. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that there is insufficient documentation in the available medical record supporting that the enrollee had either recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer, and had not been previously tested with the same test 
using NGS for the same cancer genetic content, and that she decided to seek further cancer treatment such as 
therapeutic chemotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FoundationOne CDx testing have not been met. Therefore, we decided that the 
Plan does not have to pay for FoundationOne CDx testing (0037U) provided on April 25, 2022.