Persius/hicric huggingface dataset:
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 a LTACH admission is the appropriate 
step for the enrollee's condition. The Plan denied your request. The Plan says the request 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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services beyond 
February 16, 2023. 
 
You asked the Plan to pre-approve continued inpatient mental health services. The Plan denied your request. 
The Plan says Medical necessity criteria are not met for this request. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued inpatient mental health 
services. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient 
psychiatric care. Our physician reviewer found it was not expected this enrollee would improve in a reasonable 
period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory 
or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. Our 
reviewer also found that it does not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower 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 continued inpatient mental health services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health services beyond February 
16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 8, 2022, billed with 
codes 81401, 81225, 81227, 81226, 81230, 81231, 81240, 81241, 81328, 81335 and 81291. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was 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 
July 8, 2022, billed with codes 81401, 81225, 81227, 81226, 81230, 81231, 81240, 81241, 81328, 81335 and 
81291.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (Current Procedural Terminology (CPT) 
code 72040), swallowing function x-ray (CPT 74230), radiologic examination, mandible; partial, less than 4 
views (CPT 70100), radiologic examination, teeth; partial examination, less than full mouth (CPT 70310) and 
upper gastrointestinal tract x-ray (CPT 74240) provided on September 2, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT) code 72040, swallowing function x-ray (CPT 74230), 
radiologic examination, mandible; partial, less than 4 views (CPT 70100), radiologic examination, teeth; partial 
examination, less than full mouth (CPT 70310) and upper gastrointestinal tract x-ray (CPT 74240). You say 
that the services were medically necessary. The Plan denied your request. The Plan says the services do not 
meet the Medicare coverage criteria. 
 
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 a neck/spine x-ray (CPT) code 72040, swallowing function x-ray (CPT 74230), radiologic 
examination, mandible; partial, less than 4 views (CPT 70100), radiologic examination, teeth; partial 
examination, less than full mouth (CPT 70310) and upper gastrointestinal tract x-ray (CPT 74240) have not 
been met. Therefore, we decided that the Plan does not have to pay for a neck/spine x-ray (Current Procedural 
Terminology (CPT) code 72040), swallowing function x-ray (CPT 74230), radiologic examination, mandible; 
partial, less than 4 views (CPT 70100), radiologic examination, teeth; partial examination, less than full mouth 
(CPT 70310) and upper gastrointestinal tract x-ray (CPT 74240) provided on September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that you disagree with the denial. The Plan denied 
your request. The Plan says no clinical information has been received to determine whether you meet the above 
requirements, why a new CPAP device is needed or a new CPAP device needs to be replaced. 
 
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 CPAP device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a replacement CPAP is not medically necessary because coverage criteria are not met. This 
enrollee has obstructive sleep apnea and has been using CPAP successfully since about 2015. The medical 
records do not include an order for a replacement CPAP device, or documentation that the current device is 
defective and requires replacement. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for the 
enrollees medical condition. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Testosterone 100 milligram pellet provided on November 
2, 2022. 
 
You asked the Plan to pay for the Testosterone pellet. The Plan denied your request. The Plan says this drug is 
not covered by your plan, as it does not contain any drugs that are approved by the FDA. The Plan also says 
this drug is being used to supplement hormone levels. 
 
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 pay for the Testosterone pellet. Our reviewer says 
that the Testosterone pellet was not medically reasonable and necessary for you. Our physician reviewer found 
the requested use of the Testosterone 100 milligram pellet is not FDA-approved for the enrollees diagnosis. 
Our reviewer also found that its use is not supported by one of the major drug compendia or by clinical 
research that appears in a Centers for Medicare and Medicaid Services (CMS) approved medical journal. 
 
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 Testosterone pellet have not been met. Therefore, we decided that the Plan 
does not have to pay for the Testosterone 100 milligram pellet provided on November 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 3, 2022, to 
April 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 3, 2022, to April 
1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 
30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88381, 88360, and 88342 billed for 
date of service December 30, 2021. 
 You asked the Plan to pay for procedure codes 88341, 88381, 88360, and 88342. 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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88381, 88360, 
and 88342. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88381, 88360, and 88342. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88381, 88360, and 88342 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 88341, 88381, 88360, and 88342 billed for date of service December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided on March 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was necessary and is 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 (88305) provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visits provided on June 21, 2022, and July 12, 2022. 
 
You asked the Plan to pay for the office visits. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the benefit for these services is included in the payment/allowance for 
another service/procedure. 
 
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. Review of the file shows that the Plan has stated that these services cannot be 
billed due to the benefit for these services are included in the payment/allowance for another service/procedure. 
However, the documentation does not show what service these services are included in. In addition, no 
Medicare rules were provided to support this denial. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the office visits provided on June 21, 2022, and July 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced knee system for a prosthesis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided medical records do not fully support the need for a microprocessor style knee as 
opposed to a mechanical K3 knee. The provided medical records document the enrollee has severe peripheral 
vascular disease, moderate chronic lung disease and chronic phantom limb pain requiring gabapentin and 
narcotics with a "fair" rehabilitation potential; records do not clarify why a lighter, simpler mechanical K3 knee 
would not be better suited for the enrollee's needs. 
 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 pre-approve an advanced knee system for a prosthesis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on August 6, 2022. 
 
You asked the Plan to pay for the rotary wing air transport and air mileage. The Plan denied your request. The 
Plan says the enrollee does not meet medical necessity guidelines for coverage.  
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 rotary wing air transport and air mileage. 
Our physician reviewer found the enrollee was hospitalized on August 4, 2022, with dysphagia. The enrollee 
was found to have a lung mass, for which further evaluation was medically necessary. Our reviewer found 
while transfer to a higher level of care on August 6, 2022, was reasonable, the transfer was urgent, not 
emergent. The transfer was not to the closest appropriate facility, and the unavailability of a ground ambulance 
is not a medical issue. Our physician reviewer found that as such, the use of an air ambulance was not 
medically necessary, reasonable or coverable. 
 
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 rotary wing air transport and air mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage 
(A0436) provided on August 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve these services. You say that you need the wig due to alopecia. The Plan 
denied your request. The Plan says the services are not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
20, 2021, to July 22, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the determination to remove principal 
diagnosis code A41.9 remains upheld. 
 
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 A41.9. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that in this case, there was no laboratory or clinical evidence of sepsis. The review has 
determined that the documentation did not support diagnosis code A41.9 - sepsis, unspecified organism.  
 
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 inpatient hospital services provided to the enrollee from June 20, 2021, to July 22, 2021.