Persius/hicric huggingface dataset:
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 requested IRF services are necessary because the 
enrollee has a history of recent falls, swallowing difficulties and self-care activities have become difficult due 
to reduced strength. You also say the enrollee has had a significant decrease in their ability to perform normal 
daily activities. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in 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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that they would meet criteria for admission to an IRF.  There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain their functional status.  The 
enrollee can receive further services 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of acute rehabilitation services. The Plan denied your request. The Plan says an IRF admission is not supported 
based on the records received.  
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy however, the documentation 
doesnt support that you meet criteria for admission to an acute inpatient rehabilitation facility. You can receive 
further services 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and 
electronic connection between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connection. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 an expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you have sufficient strength and function 
in upper extremities to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness 
(E2313), and electronic connection between wheelchair controller and two or more power seating system 
motors (E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148, 72149, 72158). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of an MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has lumbar pain with radiculopathy. The record does not indicate the presence of any red flag 
signs or symptoms, the failure of a trial of physical therapy, or that a surgeon has evaluated the enrollee and is 
considering surgery. The requested service is not medically necessary and reasonable for the diagnosis and 
treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not 
satisfied. The requested service cannot be 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 an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148, 72149, 
72158).
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 authorization of acute therapy for the enrollee is 
necessary to a restoration of their health. You say without it, there is a real and present risk that the enrollee 
will languish and their overall health will continue to decline. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare rules for admission to an inpatient rehabilitation facility.  
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the submitted clinical summary and clinical 
documentation support the medical necessity for IRF admission. The Plan denied your request. The Plan says 
the records show that there is no need for an intensive rehabilitation program.  
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that they would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain functional status.  The enrollee can receive further services 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81542) provided on March 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 (81542) provided on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520, 87338, and 87798 billed for June 19, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 83520, 87338, and 87798 are not supported. 
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87338 
is infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-
linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay 
[IMCA]), qualitative or semiquantitative; Helicobacter pylori, stool. The definition of code 87798 is infectious 
agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT codes 83520, 87338, and 87798 are not supported in the medical record. Specifically, there is 
not a complete description of the not otherwise specified code to support code 83520. The records show that a 
panel of testing was performed and there is a more appropriate single code for the services than 87338 and 
87798. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 83520, 87338, and 87798 
billed for June 19, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Confirm MDx testing (81551) provided on April 11, 2023. 
 
You asked the Plan to pay for the Confirm MDx testing. You say that this testing is standard of care for the 
management of men at risk for undetected prostate cancer. The Plan denied your request. The Plan says that 
criteria is not met for ConfirmMDx as the patient was not being considered for a repeat biopsy due to persistent 
risk factors such as elevated/rising PSA and/or abnormal DRE by repeat testing. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the 
Medicare rules section of this letter are met. 
 
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 Confirm MDx testing. Our reviewer says 
that this service is medically necessary. Our physician reviewer found that in this case, criteria is met for 
ConfirmMDx as the enrollee was being considered for a prostate biopsy with a PSA of 5.02. As seen in the 
second criteria, it is covered if enrollee is being considered for a prostate biopsy OR repeat prostate biopsy with 
PSA in certain range which this enrollee meets. 
 
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 Confirm MDx testing have been met. Therefore, we decided that the Plan 
has to pay for the Confirm MDx testing (81551) provided on April 11, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81226, 81240, 81241 and 81401 billed for 
April 17, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 81226, 81240, 81241 and 81401 are not supported. 
 
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 81226 is CYP2D6 (cytochrome P450, family 2, 
subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, 
*10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN). The definition of code 81240 is F2 (prothrombin, 
coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant. The definition of 
code 81241 is F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant. The 
definition of code 81401 is level two molecular pathology procedure. 
 
We find that CPT codes 81226, 81240, 81241 and 81401 are not supported in the medical record. Specifically, 
the records show that a panel was performed and there is a more appropriate single code for these services. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 81226, 81240, 81241 and 81401 
billed for April 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general services provided on February 8, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
inclusive to code J9299. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 

The general services, billed with revenue code 0250, are not separately payable. Based on this information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the general services provided on February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service June 20, 
2023.  You asked the Plan to pay for procedure code 88341. You say that these services are supported as billed. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint PNS system. 
 
You asked the Plan to pre-approve the Sprint PNS system. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the requested device is not reasonable 
and medically necessary. 
 
We reviewed the Local Coverage Determination cited by the Plan and found it was not applicable to the 
jurisdiction. 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 Sprint PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has hand and extremity pain. The Sprint PNS device is experimental 
for hand pain. 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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint PNS system.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox at the frequency of 200 units every six months. 
 
You asked the Plan to pre-approve Botox (200 units every six months). You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that the number of units requested exceeds the 
necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox (200 units every six months). 
Our reviewer says that the documentation supports that the requested Botox and frequency is medically 
reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of overactive bladder 
refractory to anticholinergic therapy. The Medicare approved drug compendia contain a supportive citation for 
the use of the requested drug as prescribed in the enrollee's clinical situation. Therefore, the enrollee does meet 
criteria for the requested drug and frequency. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox (200 units every six months) have been met. Therefore, we decided that 
the Plan has to pre-approve Botox at the frequency of 200 units every six months.  
 
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.