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

 
We decided that the Plan does not have to pay for lab services provided on October 19, 2020. 
 
You asked the Plan to pay for the lab services. You say that this claim should be allowed due to the COVID-19 
waivers that were in effect. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for lab services provided on October 19, 2020.
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 wish to regain maximum strength for 
independence. The Plan denied your request. The Plan says 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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services (99495) provided 
April 26, 2023. 
 
You asked the Plan to pay for transitional care management services. You say that this charge was correctly 
billed after the enrollee was hospitalized overnight.  The Plan denied your request. The Plan says this service or 
procedure requires that a qualifying service or procedure be received and covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of transitional care management services 
have been met. the date of service is April 26, 2023. The only records provided are for April 19, 2023. The 
records for the actual date of service needs to be provided. Therefore, we decided that the Plan does not have to 
pay for transitional care management services (99495) provided April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter and miscellaneous supplies or accessories 
(basket, cell phone holder, font basket and free raspberry and black) purchased January 5, 2023. 
 
You asked the Plan to pay for the power scooter. You say that you need the scooter for mobility to help you 
take care of your personal business when you have to go out. The Plan denied your request. The Plan says the 
power scooter does not meet the medically necessary criteria and the related accessories (basket, cell phone 
holder, font basket and free raspberry and black) are convenience items. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your 
condition can be improved by a walker, cane or manual wheelchair and you cannot safely operate the PMD 
being requested. This device is also being requested for use outside the home. The accessories are also 
convenience items that do not serve a medical purpose. This means that Medicare rules for coverage of a PMD 
have not been met. Therefore, we decided that the Plan does not have to pay for a power scooter and 
miscellaneous supplies or accessories (basket, cell phone holder, font basket and free raspberry and black) 
purchased January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 The Plan follows Medicare rules. Medicare rules say that treatment for LUTS/BPH treatment will be 
considered medically reasonable and necessary 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 transurethral waterjet ablation of 
prostate. Our reviewer says that the services are not medically necessary Our physician reviewer found the 
enrollee does not meet the coverage criteria detailed in the LCD. Waterjet ablation of prostate procedure is not 
currently approved for use in prostate cancer. However, there is ongoing research on the use of waterjet 
ablation for prostate cancer. In particular, the AQUARIUS study is a randomized controlled trial comparing 
waterjet ablation to radical prostatectomy (surgery to remove the prostate gland) in men with localized prostate 
cancer. The results of this trial are expected in 2025. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
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 IRF services are necessary and beneficial for the 
enrollee. The Plan denied your request. The Plan says the request for IRF services 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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
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: 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 would like to be admitted to an IRF as you wish 
to return to being independent as quickly as possible. The Plan denied your request. The Plan says you do not 
meet requirements for approval of 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 your nursing, medical, and rehabilitation needs are complex. However, they do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical 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 you 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the services. You say that the doctor recommends this CT scan due to the 
medical history.can due to the medical history. The Plan denied your request. The Plan says the requested CT 
scan is not a covered service per LCD guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the services. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record does not indicate that the enrollee has signs or symptoms of heart disease. The record indicates that the 
requested test is for screening purposes in an enrollee with normal lipid profile and hypertension. The provided 
records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested 
service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) (A9276). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says that the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow 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 physician reviewer 
found that the record indicates that the enrollee is now being prescribed insulin and monitoring blood sugar 
levels. Criteria for coverage is 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 been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM) (A9276).  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on March 1, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that please look into this claim and see if it can be 
reprocessed in network due to this enrollee having Medicare. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) provided on 
March 1, 2023, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ferric carboxymaltose injection (Injectafer) (J1439). 
 You asked the Plan to pre-approve Injectafer. You say that you are requesting reconsideration for the denial of 
the medication. The Plan denied your request. The Plan says 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 Injectafer. Our reviewer says that 
criteria for coverage of Injectafer have not been met. Our physician reviewer found the Plan requires a trial of 
Ferrlecit, Infed or Venofer before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 
would likely be less effective and/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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ferric carboxymaltose injection (Injectafer) (J1439).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for capsulectomy or capsulotomy; interphalangeal joint, each 
joint rendered on March 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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 26525 is "Capsulectomy or capsulotomy; interphalangeal 
joint, each joint." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the medical records 
provided do not include sufficient documentation to validate that CPT 26525 was performed as a service that 
was distinct, independent from other services performed on March 9, 2023. Therefore, this procedure cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for capsulectomy or capsulotomy; interphalangeal joint, each joint rendered on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) denervation (64625). 
 
You asked the Plan to pre-approve SIJ denervation. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called RFA) is not 
considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SIJ denervation have not been met. Therefore, we decided that the Plan does not have to pre-
approve sacroiliac joint (SIJ) denervation (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the high strength, lightweight wheelchair (K0004) non-
covered items or service, rollator and side bags for storage (A9270) purchased December 8, 2022. 
 
You asked the Plan to pay for the wheelchair and accessories. You say that you are appealing the denial of 
reimbursement. The Plan denied your request. The Plan says the items were ordered prior to receiving a 
prescription from a physician and purchased from a non-contracted, non-Medicare participating supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
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 pay for the high strength, lightweight wheelchair 
(K0004) non-covered items or service, rollator and side bags for storage (A9270) purchased December 8, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the AlloSure Kidney testing billed with code 81479 for date of service 
January 19, 2023.  
You asked the Plan to pay for the AlloSure Kidney testing. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the services billed were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that molecular diagnostic tests are covered for certain 
indications. 
 
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 AlloSure Kidney testing. Our reviewer 
says that the documentation shows that the services rendered were medically reasonable and necessary. Our 
physician reviewer found the enrollee is a kidney transplant patient. The kidney AlloSure test has been shown 
to be predictive of kidney allograft rejection. This testing can be used to adjust the pre-test probability of 
rejection and can be used to detect rejection earlier in its process, allowing earlier treatment. Therefore, the 
enrollee met criteria for the services rendered. 
 
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 AlloSure Kidney testing have been met. Therefore, we decided that the Plan 
has to pay for the AlloSure Kidney testing billed with code 81479 for date of service January 19, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 5, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 5, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500.