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

 
We decided that the Plan does not have to pre-approve upgraded electronics, M3 color kit, accessory bar, 
accessory tray, and footplate width extenders. 
 
You asked the Plan to pre-approve upgraded electronics, M3 color kit, accessory bar, accessory tray, and 
footplate width extenders. You say that the enrollee does not have the upper extremity strength, range of 
motion, dexterity, or coordination to consistently access and operate a separate switch to safely and effectively 
operate the requested power options. You say that this is heavily documented in the records. You also say that 
the enrollee is not safe to use a toggle switch. The Plan denied your request. The Plan says the notes do not 
show a medical need to control the power options through the joystick. The Plan also says that the requested 
accessory tray, accessory bar, color kit, and footplate width extension do not serve a medical purpose and 
therefore are not covered. 
 
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 upgraded electronics and footplates. 
Our reviewer says that the requested upgraded electronics and footplates are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided records indicate that the 
enrollee has sufficient upper limb strength to manage the power drives without a joystick. The reviewer also 
found that the requested footplates are included in the already approved power wheelchair. Therefore, the 
reviewer found that the requested upgraded electronics and footplates are 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 upgraded electronics and footplate width extenders have not been met. 
Additionally, the requested M3 color kit, accessory bar, and accessory tray do not serve a medical purpose and 
cannot be covered. Therefore, we decided that the Plan does not have to pre-approve upgraded electronics, M3 
color kit, accessory bar, accessory tray, and footplate width extenders.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from June 8, 2022, to 
July 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a corrected itemized bill was not received. 
 
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 services have been met. Despite 
multiple attempts from the plan, a corrected itemized bill has not been received for these services. This is 
necessary for adjudication of this claim, as the itemized bill charges ($336,970.50) are greater than the UB-04 
charges ($336,515.50). Therefore, we decided that the Plan does not have to pay for inpatient hospital services 
rendered from June 8, 2022, to July 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 15, 
2023, to August 13, 2023. 
 You asked the Plan to pay for SNF care. You say that continued SNF from July 15, 2023, to August 13, 2023, 
was medically necessary. The Plan denied your request. The Plan says the enrollee did not receive skilled 
nursing services and care was custodial only. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 15, 2023, to August 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36215-59 rendered on October 6, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedure Terminology (CPT) code 36215-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
provider performed dialysis circuit interventions which would be coded with CPT codes 36901 - CPT 36906 
which includes catheter placement. Modifier 59 is not supported and cannot be verified. 
 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 procedure code 36215-59 rendered on October 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS). 
 
You asked the Plan to pre-approve MRgFUS. You say that MRgFUS is medically necessary. The Plan denied 
your request. The Plan says MRgFUS is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MRgFUS is covered when the criteria listed in the 
Medicare rules section of this decision area 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 pre-approve MRgFUS. Our reviewer says that the 
requested MRgFUS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has essential tremor. The record provided does not 
establish that the enrollee is not a surgical candidate for deep-brain stimulation because of medical 
contraindications. The elements of the coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRgFUS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRgFUS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on 
April 04, 2023, to April 18, 2023. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you have not been 
charged for these services in the past. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for each specialist office visit. This item/service falls within the 
physician/Practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $70 ($35 copayments 
x 2 visits = $70). Therefore, we decided that the Plan does not have to waive the copayment for each specialist 
office visit provided on April 04, 2023, to April 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EUFLEXXA injections. 
 
You asked the Plan to pre-approve EUFLEXXA injections. You say that this is medically necessary for treating 
unilateral primary osteoarthritis, left knee. The Plan denied your request. The Plan says you have not tried and 
failed one of the preferred step therapy (multi-injection) device(s): Orthovisc OR Supartz FX. There is no 
indication our preferred agent(s) would likely be: less effective, and/or cause adverse effects for you. 
 
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 EUFLEXXA injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found without the details of the prior 
injection(s) that you noted to have trialed, the efficacy of Euflexxa for you cannot be clearly 
determined. Therefore, the documentation does not support that the Euflexxa injection is safe and effective for 
you. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EUFLEXXA injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve EUFLEXXA injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel test billed for date of service 
June 25, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
used for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  The panel test was billed using codes 87798, 87634, 87502, 87651, and U0002. We looked at the file and 
Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no 
evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a 
single code with one unit of service should be used. Based on this information, we decided that Medicare rules 
for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay 
for the respiratory pathogen panel test billed for date of service June 25, 2023.
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 have been approved to move over to the 
program and need this type of care following your fall. You do not want to go to a nursing home and say this is 
the therapy you need to get better. The Plan denied your request. The Plan says the requested IRF admission 
and services are 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 The complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64483-50 and 01938-QX billed for date of 
service May 1, 2023. 
 
You asked the Plan to pay for procedure codes 64483-50 and 01938-QX. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 64483 is 
bundled into payment for code 01938. Additionally, procedure code 01938 was performed as Monitored 
Anesthesia Care and is missing the correct modifier of QS. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64483 
is a column II code to column I code 01938. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, procedure code 01938 was performed as Monitored Anesthesia Care and is 
missing the correct modifier of QS. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 64483-50 and 01938-QX billed 
for date of service May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care to regain strength. The 
Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, the 
enrollee needs can be safely provided at another setting.  
 
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 enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the admission criteria, 
and their ongoing medical care warrants an LTACH level of care. The Plan denied your request. The Plan says 
the enrollee can receive the care they need at the current setting and transfer or discharge to next level of care 
when appropriate. 
 
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 have a somewhat unstable mental status and requires 
additional acute care services that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee does not require services at the LTACH that are not already available at 
the current facility. 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 and as it would not be clinically advantageous. 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 LTACH 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 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, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested 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 the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in 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.