Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49440 provided on January 27, 2023. 
 
You asked the Plan to pay for procedure code 49440. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is not separately payable. 
 
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 find that CPT code 49440 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of code 36558. A modifier was not billed to denote a separate service. Based on this 
information, we decided that Medicare rules for coverage of procedure code 49440 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 49440 provided on January 27, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for January 13, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes G0483 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only 
11 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0483 
billed for January 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or 
hospice settings, each 15 minutes (G0156x20). 
 
You asked the Plan to pre-approve the aide services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 We looked at the file and Medicare rules. The records show that you were approved for three (3) skilled 
nursing visits, twelve (12) physical therapy visits, nine (9) occupational therapy visits, and seven (7) home 
health visits with another home health aide. The records also show that you are requesting assistance with mean 
prep and light housework. The addition of another home health aide for the purpose of providing non-home 
health aide services exceeds your need. Based on this information, we decided that Medicare rules for coverage 
of the aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
services of home health/hospice aide in home health or hospice settings, each 15 minutes (G0156x20).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on February 7, 2023. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was medically necessary and should be 
paid. The Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on February 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute gastrointestinal blood loss imaging (78278). 
 
You asked the Plan to pre-approve acute gastrointestinal blood loss imaging. You say that this is medically 
necessary. 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 acute gastrointestinal blood loss 
imaging. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found provided charting does not support active gastrointestinal 
blood loss. In fact, the provider has documented that the enrollee's stool has not tested positive for occult blood 
for 6 months. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute gastrointestinal blood loss imaging have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute gastrointestinal blood loss imaging (78278).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 physical therapy (PT) visits in your home (G0121). 
 You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary for the enrollee.  The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
documentation does not support that the enrollee requires additional skilled rehabilitation (rehab) services to 
provide treatment that is medically necessary. The reviewer found that the enrollee does not require additional 
skilled rehab services to effectively provide treatment, care, and/or services in order to improve the enrollees 
condition, perform a maintenance program to maintain the enrollees condition and/or prevent deterioration. 
The reviewer also found that the enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. Therefore, the reviewer found that the requested home health services 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 physical therapy (PT) visits in your home (G0121).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor kit. 
 You asked the Plan to pre-approve the continuous glucose monitor (CGM). You say that this CGM is necessary 
for the enrollee. The Plan denied your request. The Plan says the requested CGM is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia, had an in-person visit with their treating physician to evaluate 
their diabetes control and to determine whether the criteria for coverage have been met.  Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor (CGM) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) services billed 
with codes E0666, 97760, E0673, and E0650 for November 9, 2022, to November 29, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that a PCD that provides intermittent limb compression for 
the purpose of prevention of venous thromboembolism is a non-covered preventive service. 
 
We looked at the file and Medicare rules. The file shows that the PCD services at issue were performed for the 
prevention of venous thromboemoblism. 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 
pneumatic compression device (PCD) services billed with codes E0666, 97760, E0673, and E0650 for 
November 9, 2022, to November 29, 2022.
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 you require IRF services to regain your prior level of 
functioning and independence. 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 your 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: 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 not able to walk, need therapy services, not 
able to move her legs still member in serious pain. The Plan denied your request. The Plan says your records do 
not show that you need an intensive team for your care. Services needed may be provided safely in a lower 
level of care. 
 
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. 
 
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 Syn-One testing (88305, 88341, 88342, 88356 and 88314) 
provided on April 13, 2022. 
 
You asked the Plan to pay for Syn-One testing. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this test is not clinically proven and therefore is not considered 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 Syn-One testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Syn-One is an a-synuclein skin biopsy test used for the detection of the pathology in 
Parkinson disease (PD), dementia with Lewy bodies (DLB), multiple system atrophy (MSA), and pure 
autonomic failure (PAF). The clinical value of the test has not been demonstrated in the peer reviewed 
literature. The review has determined that the items/services at issue in this case were 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 Syn-One testing have not been met. Therefore, we decided that the Plan does 
not have to pay for Syn-One testing (88305, 88341, 88342, 88356 and 88314) provided on April 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires ongoing acute medical 
management in addition to intensive rehabilitation to successfully return home and avoid future readmission. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, the enrollee can 
safely receive the services they need in other settings.  
 
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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
December 2, 2022. 
 You asked the Plan to pay for procedure codes 87481 and 87653. The Plan denied your request. The Plan says 
payment for codes 87481 and 87653 is bundled into payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 87481 and 87653 billed for 
date of service December 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T9-12 and L4 kyphoplasty (22513, 22514, 22515). 
 
You asked the Plan to pre-approve T9-12 and L4 kyphoplasty. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve T9-12 and L4 kyphoplasty. Our 
reviewer says that the enrollee does not meet coverage criteria. Our physician reviewer found detailed 
documentation is not evident regarding any acute or subacute fractures of the thoracic and/or lumbar spine. 
Moreover, there is no documentation of any fracture at the T10, T11, or T12 vertebral bodies. The L4 
compression fracture was noted to be present on the 2019 imaging study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T9-12 and L4 kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve T9-12 and L4 kyphoplasty (22513, 22514, 22515).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
February 7, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says a free-standing emergency facility is not eligible to 
enroll in Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0747). 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a bone growth stimulator is covered for non-union of 
a long bone fracture defined as radiographic evidence that fracture healing has ceased for three or more months 
prior to starting treatment with the osteogenesis stimulator. 
 
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 bone growth stimulator. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found current peer-reviewed literature indicates that further large, randomized, controlled trials are required to support the use of electrical 
bone growth stimulators in the treatment of long-bone non-unions. The x-rays provided do not show continued 
non-union. 
 
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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator (E0747).
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 fell at home, has no support, cannot care 
for self alone and needs major help to get back to being independent. The Plan denied your request. The Plan 
says the enrollee's records do not show the need for an intensive team for care. Services needed may be 
provided safely in a lower level of care. 
 
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. 
 
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.