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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the request 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although the 
enrollee needs physical and occupational therapy and could tolerate the therapy in the IRF, the complexity of 
their condition doesnt require an IRF stay and care can be provided in a lower level.  
 
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 member meets LTACH criteria and 
can be transferred to the LTACH level of care for continuation of complex medical needs that require ongoing 
acute care. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), 
with any type of side rails, with mattress (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested hospital bed is 
medically necessary due to pain. The Plan denied your request. The Plan says the clinical information provided 
does not show you meet medical necessity criteria for this type of hospital bed. The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you are noted to have 
joint pain and some difficulty with mobility. However, the physical examination notes that you have a stable 
gait and there is no documentation regarding your level of independence with daily activities, transfers, and 
mobility. The documentation does not indicate that you are unable to re-position yourself while in bed and 
require frequent re-positioning or an immediate change in position, which is required for a semi-electric 
hospital bed versus a standard hospital bed. It is unclear why a standard hospital bed would not suffice if you 
required positioning given your back pain and why modifications with standard mattress or bed will not work. 
Therefore, the requested semi-electric hospital bed (E0260) is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), with any type of 
side rails, with mattress (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454). 
 
You asked the Plan to pre-approve the genicular nerve procedure. You say that the enrollee will significantly 
benefit from the genicular nerve block/radiofrequency ablation. The Plan denied your request. The Plan says 
the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve procedure. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found a genicular nerve injection for knee pain is experimental and more research is 
needed. 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 genicular nerve procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the injection of an anesthetic or steroid into the genicular nerve (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service May 30, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria. 
 
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. The records show that a combined cardio and pharmacogenomics 
panel test was provided. The need/attestation for the testing was not documented until after the testing was 
performed. There are no recent medical records within the six months prior to testing that indicates the 
physicians intent for the testing to be performed. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the panel 
testing billed for date of service May 30, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on July 20, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that this claim was recouped by Medicare since 
the enrollee had a different primary insurance. The Plan denied your request. The Plan says this claim was 
submitted after the timely filling limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 The record shows that a claim for the nursing facility care was not filed until May 18, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the nursing facility care provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
May 31, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 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 and 87798 are not supported in the medical record. Specifically, these codes are 
"not otherwise specified" codes. The provided records do not indicate what test(s) were provided under codes 
83520 and 87798. Codes 83520 and 87798 cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 83520 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service May 31, 
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 current facility cannot give you the needed 
therapy. The Plan denied your request. The Plan says the denial of IRF care is correct.  
 
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 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. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required 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 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 pay for a follow-up inpatient consultation provided out-of-network 
(OON) on July 23, 2022.  
 
You asked the Plan to pay for the follow-up inpatient consultation provided OON. You say that the medical 
records provided support that payment is due for the claim in dispute. The Plan denied your request. The Plan 
says the OON services were not per-authorized. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 follow-up inpatient consultation 
provided OON. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer 
found the enrollee was admitted on July 18, 2022, for elective back surgery. The procedure was done as 
planned. As of July 21, 2022, he was working with Physical Therapy (PT). He required contact guard assist 
only. He was able to tolerate 3 hours of PT and other rehabilitation each day. He was medically stable and was 
ready for transfer to a lower level of care. The treating physician did not document (in the physician notes, on a 
form, or in an order) that the patient was not stable for transfer on July 23, 2022. 
 
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 follow-up inpatient consultation provided OON have not been met. 
Therefore, we decided that the Plan does not have to pay for a follow-up inpatient consultation provided out-of-
network (OON) on July 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Go Go Ultrax three (3) wheeled scooter (E1399). 
 
You asked the Plan to pre-approve a 3 wheeled scooter. You say that the PWC you received does not fit in your 
home; it is too big. You need a wheelchair that allows you to move around your home. The Plan denied your 
request. The Plan says 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a 3 wheeled scooter have not been met. Specifically, the requested scooter has not been reviewed 
by PDAC. It is not found to meet the definition of a specific POV/PWC and is therefore, not reasonable, and 
necessary. Therefore, we decided that the Plan does not have to pre-approve a Go Go Ultrax three (3) wheeled 
scooter (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars that are less than 54 that persist despite adjustment in medications. 
Although both notes from August and June document blood sugars of 58 and in the 60s there is no evidence of 
medication adjustments to prevent the low blood sugars. Furthermore, Ozempic and Metformin do not usually 
cause low blood sugars; hence, although a CGM might help this enrollee, the coverage criteria are not 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 the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, with 
mattress (E0303), a sling or seat, patient lift (E0621) and a patient lift, hydraulic or mechanical (E0630). 
 
You asked the Plan to pre-approve a heavy-duty hospital bed and a patient lift. You say that you have gained 
weight, and you need a bariatric bed and lift of bariatric size. You also say the equipment from 2022 no longer 
works, the lift can no longer support your new weight and the bed is a twin sized bed and you no longer fit in it. 
The Plan denied your request. The Plan says Medicare allows purchasing of medical equipment once every 5 
years and that is only if the equipment is repairable or cannot be repaired. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. The records show that your current equipment 
accommodates a weight capacity of up to 450 pounds. The records also show that you have had weight gain, 
but you are not over 450 pounds. Therefore, we decided that the Plan does not have to pre-approve a hospital 
bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 
pounds, with any type of side rails, with mattress (E0303), a sling or seat, patient lift (E0621) and a patient lift, 
hydraulic or mechanical (E0630).
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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the 
IRF services requested do not meet the requirements for approval.  
 
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 clinical documentation shows the enrollee has active medical comorbidities and 
complex functional impairments (hip fracture is an inpatient rehabilitation facility compliant diagnosis) thus the 
complexity of the enrollee's nursing, medical and rehabilitation needs would be expected to require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. However, skilled therapy has 
been severely limited by pain and nausea thus the enrollee would not be expected to tolerate or significantly 
benefit from an intensive rehabilitation regimen in an IRF 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided July 17, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please reconsider and reprocess this claim. 
PrismRA is only available through you and should be considered medically necessary for the enrollee. The Plan denied your request. The Plan says under Medicare guidelines, your request is not medically necessary 
because your records show this test is not FDA approve. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record provided document that this test, PrismRA has not been 
cleared or approved by the FDA. Online search of the FDA list of cleared or approved companion diagnostic 
testing does not mention this PrismRA. Search of the DEX Diagnostic Exchange registry for the diagnostic 
program MolDX Technical Assessment, states that this PrismRA test is not covered. Based on this information, 
we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we 
decided that the Plan does not have to pay for the PrismRA testing (81479) provided July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneDose Genetic response report panel and a Hereditary 
Genetic Cardiac test panel performed on May 15, 2023. 
 
You asked the Plan to pay for genetic testing. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says these tests were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the GeneDose Genetic response report panel and Hereditary Genetic Cardiac test panel are not 
standard of care and were not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for GeneDose Genetic response report panel and a Hereditary Genetic Cardiac test panel performed 
on May 15, 2023.