Persius/hicric huggingface dataset:
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 the enrollee's needs are too complex for a lower level 
of care. 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
radiopharmaceutical localization of tumor. 
 
You asked the Plan to pre-approve SPECT test. You say that this scan has almost a 100% chance to diagnose if 
you have Parkinson's. The Plan denied your request. The Plan says this 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 SPECT test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are suspected of having Parkinson's Disease. In general, Parkinson's is diagnosed on a 
clinical basis using the validated diagnostic criteria. In this case there was not clear evidence of any form of 
"overlapping" condition. A diagnosis of Parkinson's could be made based on the symptoms and examination findings alone. It cannot be concluded that the requested scan would be the most appropriate type of service 
that could be provided to you at the moment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve single photon emission computed tomography (SPECT) radiopharmaceutical localization 
of tumor.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the enrollee has gastroesophageal reflux disease and is 
not able to take any other medications. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug bisphosphonate. Also, there is no indication that the Plan's required drug would likely be less 
effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 93623. We decided that the Plan does not have to pay 
for procedure code 75820.  
 
You asked the Plan to pay for procedure codes 93623 and 75820 billed for date of service November 14, 2022. 
You say that these services were necessary and are supported as billed. The Plan says that these codes are not 
supported in the documentation provided. 
 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 decided that the Plan has to pay for procedure code 93623.  
 
In this case, the CPT Code Manual definition of code 93623 is programmed stimulation and pacing after 
intravenous drug infusion (List separately in addition to code for primary procedure). 
 
We asked our coder 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 procedure code 93623. Our reviewer says that code 93623 is 
supported in the record. Our reviewer found that the documentation states that this procedure was performed. 
According to CPT rules, this procedure can be reported separately as an add-on code with a cardiac ablation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93623 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 93623.  
 
We also decided that the Plan does not have to pay for procedure code 75820. 
 
In this case, the CPT Code Manual definition of code 75820 is venography, extremity, unilateral, radiological 
supervision and interpretation. 
 
We asked our coder 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 procedure code 75820. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found that the record does not state that a unilateral 
venography of an extremity was performed on the date in question. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 75820 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 75820. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0299, G0300, G0496, 
Q5001) provided on May 2, 2023, to May 24, 2023. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 27, 2023. The NOA was not received by the Plan until June 26, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, G0299, 
G0300, G0496, Q5001) provided on May 2, 2023, to May 24, 2023.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's records do not 
show that they need continued treatment and care that can only be given in a hospital setting. 
 
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 record indicates that the enrollee is improving but still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH facility. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that you would like to continue therapy since 
it has helped with balance and walking with a cane. The Plan denied your request. The Plan says the requested 
services are not medically reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the notes do not indicate a need for continued therapy based on 
response to previous therapy. Endurance training and strength training are repetitive exercise and do not require 
input from a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee requires a lower level of care from an 
IRF to a SNF. The Plan denied your request. The Plan says the SNF services requested do not meet the 
requirements for approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 
setting. Required services can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision excessive skin/tissue and an abdomen 
pannicelectomy. 
 
You asked the Plan to pre-approve excision excessive skin/tissue and an abdomen pannicelectomy. You say 
that infections are reoccurring, and the final recommendation is surgical excision. The Plan denied your 
request. The Plan says this surgery is considered plastic surgery/cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 excision excessive skin/tissue and an 
abdomen pannicelectomy. Our reviewer says that this procedure is not medically necessary. Our reviewer 
found the record indicates that the enrollee has had significant weight loss following bariatric surgery. The 
record provided does not document the presence of a pannus that extends below the level of the pubic 
symphysis and chronic intertrigo refractory to three months conservative treatment or functional impairment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excision excessive skin/tissue and an abdomen pannicelectomy have not been 
met. Therefore, we decided that the Plan does not have to pre-approve excision excessive skin/tissue and an 
abdomen pannicelectomy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27513 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 27513. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 27513 is: Open treatment of femoral supracondylar or 
transcondylar fracture with intercondylar extension, includes internal fixation, when performed. 
 
We find that CPT code 27513 is not supported in the medical record. Specifically, a procedure report for the 
date of service billed was not provided for review. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Based on this information, we decided that Medicare rules 
for coverage of procedure code 27513 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 27513 billed for date of service August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 20, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, 87500. 
 
You asked the Plan to pay for the billed services. You say that the coding is approved by Medicare. The Plan 
denied your request. The Plan says there is a more appropriate code that should be billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that urinary tract infection panel testing was provided. We looked at the file and Medicare rules. 
The panel test was not billed with a single code as required. 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 genetic testing provided on April 20, 2023, billed with codes 87481, 87491, 87563, 
87640, 87653, 87798, 87641, 87500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes U0003 and U0005 billed for date of service 
January 24, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that the testing services at issue were reimbursed by 
the Plan on March 6, 2023. A comparison of the two claims shows that these are exact duplicates. There is no 
evidence to support that the billed services were provided twice on the same date. Based on this information, 
we decided that the Medicare rules for the billed services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes U0003 and U0005 billed for date of service January 24, 2023.
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 enrollee requires deep suctioning of 
the trachea every 2 to 3 hours which stops them from going to a lower level of care such as sub-acute 
rehabilitation. You also say that the enrollee has been in the hospital for 46 days with multiple stays in the 
intensive care unit. The Plan denied your request. The Plan says the enrollee does 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 continues to receive acute care services and these have not been denied.  
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. Our reviewer found that the elements of the coverage rules are 
not satisfied. Our physician reviewer also found that 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViaDisc procedure at L5-S1. 
 
You asked the Plan to pre-approve a ViaDisc procedure. You say that the goal of this treatment is to 
supplement tissue loss due to disc degeneration, which may improve pain and overall quality of life. The Plan 
denied your request. The Plan says a Via Disc Implant is a service which is experimental and investigational.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ViaDisc procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 ViaDisc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ViaDisc procedure at L5-S1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional trips are 
necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.