Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that the provider has expressed that this is necessary in 
order to treat your diagnosis of cancer. The Plan denied your request. The Plan says there is not enough 
evidence that this type of radiation therapy guidance is needed or effective for your skin cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that usually IGRT is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to you for which the target lesion can be 
seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280) and/or IGRT 
for a technology for which need has not been established by published data or supported by consensus 
guidelines (many of which recommend against treatment with these devices in general) is not necessary. The 
decision is unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT) (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with bupivacaine provided on June 29, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (64450) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for treatment with bupivacaine provided on June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee remains a great candidate for acute 
inpatient rehabilitation and meets all guidelines for admission. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines for services in 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: 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 benefit from short term IRF care to 
improve functional mobility. The Plan denied your request. The Plan says IRF care is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs 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. 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 need IRF services to get back to your physical 
baseline. The Plan denied your request. The Plan says you do not meet the criteria for IRF services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 6, 2023, and billed with codes 87481 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 this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR 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 April 6, 2023, and billed with codes 87481 and 87798.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Freestyle Libre 3 device. 
 
You asked the Plan to pre-approve the device. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says that the service is not a covered benefit. 
 
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 device. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that the coverage criteria requires insulin use. You are using insulin and are likely at risk for low blood glucose readings. You are 
an ideal candidate for the Freestyle Libre 3. 
 
We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of the device have been met. Therefore, we decided that the Plan has 
to pre-approve the Freestyle Libre 3 device.  
 
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: 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 a lower level of care is not sufficient or equipped to 
address the enrollee's needs. The Plan denied your request. The Plan says that the enrollee does not meet all the 
requirements 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item is deemed experimental and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this patient's condition or in widespread use for this patient's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this patient. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the powered upper extremity range of motion assist device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 and 88312 billed for date of service 
June 15, 2023. 
 You asked the Plan to pay for procedure code(s) 88305 and 88312. The Plan denied your request. The Plan 
says these codes are included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305 and 88312. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305 and 
88312. Based on this information, we decided that Medicare rules for coverage of procedure code 88305 and 
88312 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88305 and 88312 billed for date of service June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 16, 
2023.  
 
You asked the Plan to pay for procedure code 81456. The Plan denied your request. The Plan says payment for 
code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II 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 81456 billed for date of service January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 11, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paring of hyperkeratotic lesions (11055, 11056), nail 
debridement (11721) and a residence visit for the evaluation and management of an established patient (99350) 
provided on May 30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for paring of lesions, nail debridement and a residence visit. You say that the 
services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for payment for out-of-network services have not been met. Payment for the services denoted by code 11055 is 
bundled into payment for code 11056. 
 
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. Medicare rules also say that providers must report services 
correctly. Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 11055 is a column II code to column I code 11056 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria for code 11055 have not been met. 
 
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 paring of lesions, nail debridement and residence visit at issue in this 
appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan 
to pay for these services.  
 
Therefore, we decided that the Plan does not have to pay for paring of hyperkeratotic lesions (11055, 11056), 
nail debridement (11721) and a residence visit for the evaluation and management of an established patient 
(99350) provided on May 30, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 23, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 1, 2022, to 
November 30, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted a corrected claim and the 
required NOA. 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 October 2, 2022. The NOA was not received by the Plan until January 5, 
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 provided 
from November 1, 2022, to November 30, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 You asked the Plan to pre-approve Synvisc. You say that you are requesting reconsideration based on medical 
necessity. 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 Synvisc. Our reviewer says that the 
criteria for coverage of Synvisc have not been met. Our physician reviewer found step therapy requires that one 
of the preferred viscosupplemental treatments, Orthovisc or Supartz FX, be trialed first. The documentation 
does not outline contraindications or reasons these medications were not considered or that the Plan's additional 
required drug 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).