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 enrollee will receive the appropriate level of care 
in the acute rehabilitation setting, which will provide the best chance for a full recovery. The Plan denied your 
request. The Plan says IRF services are not medically necessary, and skilled therapies as an outpatient or home 
healthcare may be approved upon request.  
 
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's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 lab panel provided on July 21, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58761, this type of testing must be billed with a single unit of service of a single code. 
 
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.  
 
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 lab panel provided on July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LegXercise Pro exercise device (A9999). 
 
You asked the Plan to pre-approve the exercise device. You say that your doctor has recommended this device 
so you can continue your therapy at home. You do not drive and is unable to go to outpatient physical therapy. 
The Plan denied your request. The Plan says this item is not a covered benefit. The requested supplier is not 
certified with Medicare. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules say that Medicare payment cannot be made to a provider that is not enrolled in the 
Medicare program. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Review of the 
file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pre-approve the LegXercise Pro exercise device (A9999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service March 24, 
2023, to March 30, 2023.  
 
You asked the Plan to pay for procedure code 88341. You say that these services are supported in the medical 
record. 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 billed 14 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 March 24, 2023, to March 30, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric level of care as of 
November 29, 2023. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the records demonstrate that a lower 
level of care is not possible. The Plan denied your request. The Plan says the needed care can be safely 
provided in another setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet criteria for continued inpatient psychiatric care. Our physician reviewer 
found it is not expected that this enrollee will improve in a reasonable period of time beyond November 29, 
2023, as the enrollee is not showing any dangerousness to self or others, auditory or visual hallucinations, or 
aggressive behaviors. It does not appear medically reasonable and necessary to have continued psychiatric care 
provided at the inpatient level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric level of care as of November 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you need the second wheelchair for ease of 
getting in and out of a vehicle. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed 
for use inside the home. 
 
The file shows that you have an ultralightweight wheelchair. The current wheelchair serves the same purpose as the requested wheelchair. Furthermore, the file shows that you are requesting the wheelchair for use outside 
of the home and Medicare does not cover this item for that use. Therefore, we decided that the Plan does not 
have to pre-approve an ultralightweight wheelchair.
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 requires admission to an IRF. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the Medicare criteria for an IRF 
admission.  
 
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. Although the 
enrollee requires treatment by multiple therapies, including physical and occupational therapy, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health targeted case management. 
 
You asked the Plan to pre-approve mental health targeted case management. You say that mental health 
targeted case management is medically necessary. The Plan denied your request. The Plan says mental health 
targeted case management is not medically necessary. The Plan says the member did not appear to have a 
severe mental illness, recent need for hospital or institutional care, or serious dysfunction in daily living. 
 
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 mental health targeted case 
management. Our reviewer says that the requested mental health targeted case management is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that based on review the records 
provided, the documentation shows the patient to be taking trazodone 50 mg at bedtime as needed. There is no documentation that this patient is involved with therapy or the reason for the requested services. Based on 
review the records provided, utilizing Current Procedural Terminology (CPT) T1017, because of the lack of 
documentation, this patient does not require targeted case management services for the treatment of Major 
Depressive Disorder, Recurrent, Moderate and Insomnia Disorder, Unspecified as it is not considered 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mental health targeted case management have not been met. Therefore, we 
decided that the Plan does not have to pre-approve mental health targeted case management.
Appeal type: Drugs
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 you have been on Prolia since 2019 to treat your current 
medical condition. The Plan denied your request. The Plan says the necessary documentation was not provided 
to determine the medical necessity of the requested drug. 
 
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 Prolia. Our reviewer says that the 
requested drug does not meet the criteria to be determined as medically reasonable and necessary. Our 
physician reviewer found that the record indicates that you have a history of diagnosis of osteoporosis without 
pathologic fracture. The FDA has stated that the requested drug is indicated for your condition; However, the 
record provided is insufficient to establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is a non-covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on June 22, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all home health prospective payment system (HH PPS) 
claims must be submitted with type of bill (TOB) 0329. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 0329 
TOB code. 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 the home health services rendered on 
June 22, 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 LTACH is the safest and most efficient 
care level based on the pulmonary management required, comorbidities and the intensity of care the enrollee 
requires. The Plan denied your request. The Plan says the records do not show that it is medically safe for the 
enrollee to leave the hospital. 
 
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 can continue receiving their care in the acute care hospital until such 
time when no services are needed. They can then transfer or discharge to 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prosthesis, flex-walk system or 
equal (L5981). 
 
You asked the Plan to pre-approve an all-lower extremity prosthesis. You say that the enrollee enjoys fishing 
and taking walks through the woods on uneven terrain. He is young and active; if the K3 foot is not approved, 
he will go backwards into a K2 foot that would be more suited for an elderly enrollee in a nursing home. The 
Plan denied your request. The Plan says the request for a K3 foot does not meet Medicare criteria as reasonable 
and 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 an all-lower extremity prosthesis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the certified prosthetist/orthotist (CPO) states that the enrollee is a K3 
ambulator, but the documentation is conflicting as the July 13, 2023, document notes that the enrollee has a 
moderate prior general lifestyle, is on disability, gets short of breath, walks 35% of the time, is in pain 
management, has lumbar pain with sciatica, and uses a cane all of the time. Furthermore, the nurse practitioner 
note does not corroborate that the enrollee is a K3 ambulator. The nurse practitioner documentation does not 
discuss the enrollee's ambulatory level or support the prosthetist's claims of the enrollee's need for the K3 level 
foot or why the enrollee's activity needs cannot be met with a K2 level foot. 
 
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 all-lower extremity prosthesis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an all-lower extremity prosthesis, flex-walk system or equal (L5981).
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's clinical condition meets full IRF 
criteria. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria 
for admission to 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 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. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation 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 procedure code G0483 billed for date of service July 6, 2023.  
 
You asked the Plan to pay for procedure code G0483. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code G0483 is bundled into payment for code 80307. 
 
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 G0483 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. 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 code G0483 billed for date of service July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 31, 2023, and billed with codes 87556, 87641, 87653, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that per LCA A58761, this type of testing must be billed with a single unit 
of service with a single code. 
 
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.  
 
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 urine polymerase chain reaction (PCR) panel testing provided on July 31, 
2023, and billed with codes 87556, 87641, 87653, and 87798.