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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that your functionality is not at a level to allow access to 
your current living arrangement. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing or therapy needs. Your care needs 
can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG) extended monitoring provided 
on January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an EEG. You say that this should be covered. The Plan denied your request. The 
Plan says they were correct in their decision. There was no preauthorization for this test with an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for electroencephalogram (EEG) extended monitoring 
provided on January 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services (99153) provided on March 8, 2022. 
 
You asked the Plan to pay for the sedation services. The Plan denied your request. The Plan says this is not 
payable. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is 
not paid in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the sedation services (99153) provided on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustable bed received on May 13, 2022. 
 
You asked the Plan to pay for the adjustable bed. You say that you were told that this item was a covered 
benefit. The Plan denied your request. The Plan says the item received is not a covered benefit when provided 
by a provider that does not accept Medicare payments. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the adjustable bed received on May 13, 
2022.
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. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to be currently 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. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the 
enrollee is not yet stable for transfer and as it would not be clinically advantageous at this time. Completion of 
treatment at the current facility is recommended. 
 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 needs to be approved for inpatient 
rehabilitation. The Plan denied your request. The Plan says that an intensive rehabilitation program 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that the enrollee has an IRF compliant diagnosis (metabolic 
encephalopathy), and is still not at baseline with cognitive deficits and dysphagia along with other active 
comorbidities that would require close medical monitoring on an inpatient basis during rehabilitation. Our 
reviewer also found that the evaluating therapists recommend intense therapy, requiring all 3 disciplines of 
therapy thus IRF criteria have been 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging guidance services. 
 
You asked the Plan to pre-approve the requested services. You say that the therapeutic intervention assures 
complete removal of the tumor. The Plan denied your request. The Plan says there is not enough medial 
evidence to show this treatment is effective for the enrollee's cancer. 
 
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 requested services. Our physician 
reviewer found that using ultrasound on a daily basis is not unreasonable, but to bill for daily simple 
simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines. Daily simulations or IGRT would not be furnished in accordance with 
accepted standards of medical practice. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve imaging guidance services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code 20936. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 20936 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service February 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the rehabilitation so you can recover as 
soon as possible. The Plan denied your request. The Plan says the Medicare criteria for IRF admission were not 
met and the enrollee's medical needs can be provided at a lower level of care like at a skilled nursing facility 
(SNF). 
 
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 is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. At the current functional level, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. The enrollee needs physical therapy and occupational therapy in an alternate setting. 
 
The documentation does not support necessity for admission to an IRF due to lack of medical complexity and 
nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's 
rehabilitation needs can be provided in a lower intensity and alternate setting such as in a SNF. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, posterior or posterolateral technique, 
single interspace; lumbar (CPT code 22612) and posterior non-segmental instrumentation (eg, Harrington rod 
technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at 
C1, facet screw fixation) (22840). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this service is considered experimental and investigational as it is not identified as 
widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed 
medical literature published in the English language. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Minuteman device at L2-3, in this 
case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the arthrodesis, posterior or posterolateral technique, single interspace; lumbar (CPT code 
22612) and posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 
interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (22840).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1846). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a custom fabricated orthosis is covered when there is 
a documented physical characteristic which requires the use of a custom fabricated orthosis instead of a 
prefabricated orthosis. 
 
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 knee orthosis. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the knee orthosis is not medically 
necessary. The documentation does not reveal a physical characteristic that require the use of a custom 
fabricated orthosis instead of a prefabricated orthosis. There is no evidence of a knee deformity on an objective 
physical exam. There is no evidence of minimal muscle mass to suspend the orthosis. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1846).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced-foot components (L5968, L5981, L5988). 
 
You asked the Plan to pre-approve advanced-foot components. You say that the requested components are a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested components are not medically necessary. 
 
The Plan follows Medicare rules. The rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the enrollees potential functional abilities. 
 
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 advanced-foot components. Our 
reviewer says that the requested components are not medically reasonable and necessary in this case. Our 
physician reviewer found that, based on the medical records provided, there is no documentation that you have 
experienced a change or development in your condition that necessitates the requested advanced-foot components. In addition, provided records do not document that your current K3 level foot has been irreparably 
damaged, lost or stolen to meet criteria for replacement with the requested device(s). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of advanced-foot components have not been met. Therefore, we decided that the 
Plan does not have to pre-approve advanced-foot components (L5968, L5981, L5988).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 20610, 73562, G0463, and J1040 provided on May 5, 
2022. 
 
You asked the Plan to pay for codes 20610, 73562, G0463, and J1040. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT codes 20610, 73562, G0463, and J1040 are not supported in the medical record. Specifically, 
billed procedure code 20610 is a type T procedure and was billed with code G0463 that denied with reason 
medical visit on the same day as a type T or S procedure without modifier 25. The claim cannot be paid when 
one or more type T or S procedures occur on the same day as a line item containing an evaluation and 
management code that is billed without modifier 25.  Based on this information, we decided that Medicare rules for coverage of codes 20610, 73562, G0463, and 
J1040 have not been met. Therefore, we decided that the Plan does not have to pay for codes 20610, 73562, 
G0463, and J1040 provided on May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter (A9277). 
 
You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that the requested transmitter is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee did not meet the 
step therapy criteria. The provider did not send a statement that explains why the enrollee cannot use the 
preferred product or if the enrollee has tried and failed a preferred product (Freestyle Libre Flash Line or 
Freestyle Libre 2 Products) first. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes. 
 
We looked at the file and Medicare rules. The EOC confirms that the Plan will not cover other brands unless 
the provider tells the Plan why it is medically necessary. The documentation indicates that the provider did not 
send a statement that explains why the enrollee is unable to use the preferred product. Based on this 
information, we decided that Medicare rules for coverage of a Dexcom G6 transmitter have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 transmitter (A9277).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GTC (genomic testing cooperative) Hematology Profile (81479) 
provided on March 10, 2022. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that this test was approved by the MolDX 
program and is medically necessary for this enrollee. The Plan denied your request. The Plan says that there are 
Medicare coverage determinations which indicate that panels including the FANCC and BLM genes are not 
covered. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDx contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile have been met. Therefore, we decided that the Plan has to pay for the 
GTC (genomic testing cooperative) Hematology Profile (81479) provided on March 10, 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 pay for the compression stockings identified with code A6549 that 
were issued on April 4, 2022. 
 You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the services billed were rendered by an 
ineligible provider per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
August 11, 2021, have been met. Specifically, the provider did not send records to support that the testing was performed, or that show the pathologist is eligible to be paid. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on August 11, 2021.