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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is so weak and would benefit from 
getting therapy. The Plan denied your request. The Plan says the SNF services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 
facility. Therefore, admission to a SNF for inpatient skilled rehabilitation services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 27, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed services. 
 
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 27, 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 you need intense rehabilitation to get stronger and 
return home to care for yourself. You want to be in a facility with all day nursing care and doctors. The Plan 
denied your request. The Plan says that admission to an IRF is not medically necessary and does not meet the 
criteria for coverage.  
 
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. You were admitted for 
surgical management of renal cell carcinoma and a thrombus of the inferior vena cava. There are no complex 
nursing or rehabilitation needs. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on July 12, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on July 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 7, 2023, to 
April 14, 2023.  
 
You asked the Plan to pay for home health services. You say that the services should be covered as the enrollee 
disagrees with the denial. 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 pay for home health services. Our physician 
reviewer found that there is no evidence that the enrollee required or received home health services (HHS) 
during the date of service (DOS) in question. Furthermore, 99070 is a bundled service and is not separately 
billable. As such, the billing of 99070 for multiple DOS is not supported. 
 
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 pay for the home health services provided on January 7, 2023, to April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services for billed code 27596 rendered 
on July 26, 2023. 
 
You asked the Plan to pay for these services. You say that modifier 80 is attached and should be paid. The Plan 
denied your request. The Plan says an assistant surgeon is not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 27596. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon 
services for billed code 27596 rendered on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows 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 in this case, the record indicates that the enrollee has diabetes. The record provided does not indicate 
that the enrollee is being treated with insulin or has problematic hypoglycemia as defined by the Medicare 
rules. The elements of the coverage criteria are not satisfied. The requested items are not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of any joint of the upper extremity.  
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says imaging requires six weeks of provider directed 
treatment to be completed. This must have been completed in the past three months without improved 
symptoms. Contact (via office visit, phone, email, or messaging) must occur after the treatment is completed. 
The provider directed treatment did not occur within the last three months. Symptoms must be the same or 
worse after treatment to support imaging.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested imaging is not medically necessary. Our physician reviewer found there is no documentation of 
physical therapy or any red flag concerns such a tumor or fracture. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI of any joint of the upper extremity.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DXA, bone density study provided on March 2, 2023. 
 
You asked the Plan to pay for the DXA, bone density study. You say that you cannot afford to pay the billed 
amount. The Plan denied your request. The Plan says that your benefit for the requested item or service has 
already been exhausted. 
 
The Plan must follow Medicare rules. These rules say that Medicare pays for a screening BMM once every 2 
years (at least 23 months have passed since the month the last covered BMM was performed). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the DXA, bone density study have not been met. Therefore, we decided that the Plan does not have 
to pay for the DXA, bone density study provided on March 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
August 01, 2023. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic tests/Medicare-coveredradiological diagnostic services. 
 
You have been asked to pay a $150 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/Medicare-coveredradiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for outpatient diagnostic tests provided on August 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee-shin prosthetics (L5828, L5845, L5848, L5856). 
 
You asked the Plan to pre-approve the knee-shin prosthetics. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare does not pay for any items or services that 
are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member.  
 
 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 knee-shin prosthetics. Our physician 
reviewer found that based on the record provided criteria have not been met for the following items L5828, 
L5845, L5848, L5856 as Medicare does not pay for any items or services that are not reasonable and necessary 
for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 
The physician documentation does not reveal medical reasons that support that the enrollee's activities cannot 
be met with a mechanical knee. The features included in the requested equipment are not a medical necessity 
and are convenience features. The enrollee's needs can be safely and effectively met with a less complex knee 
prosthetic. 
 
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 knee-shin prosthetics have not been met. Therefore, we decided that the 
Plan does not have to pre-approve knee-shin prosthetics (L5828, L5845, L5848, L5856).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on September 8, 2022. 
 
You asked the Plan to pay for lab tests. You say that this testing was ordered based upon the treating 
physician's determination of medical necessity. The Plan denied your request. The Plan says these codes are 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 87899 is infectious agent antigen detection by 
immunoassay with direct optical (ie, visual) observation; not otherwise specified and 87900 is infectious agent 
drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 lab tests. Our reviewer says that these codes do not meet criteria for payment. Our reviewer found these procedures were not included in the medical record and 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 lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on September 8, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for code G0480 for date of service July 20, 2023. 
 
You asked the Plan to pay for code G0480. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that any claim that was affected by the procedure-to-
procedure edits, including those that did not apply an NCCI modifier, will be processed and paid as appropriate 
under existing payment and coverage policies. 
 
We looked at the file and Medicare rules. Review of the file shows that the NCCI edit created by CMS was 
issued in error. This means code G0480 should not be denied due to an NCCI edit. Based on this information, 
we decided that Medicare rules for coverage of code G0480 have been met. Therefore, we decided that the Plan 
has to pay for code G0480 for date of service July 20, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyelid surgery. 
 
You asked the Plan to pre-approve eyelid surgery. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested services does not meet the 
requirements for approval. 
 
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 eyelid surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has gender dysphoria. The record provided is insufficient 
and does not document visual functional impairment that supports the medical necessity 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 eyelid surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eyelid surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician or allowed practitioner certification provided on 
July 17, 2023. 
 
You asked the Plan to pay for physician or allowed practitioner certification. You say that this service is 
supported in the records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physician or allowed 
practitioner certification provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 4, 2022, billed 
with procedure codes 95938, 95939, 95870 (x2) and G0453. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the service provided was 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 pay for the practitioner services provided. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the neck contusion diagnosis submitted with this request does not 
match the testing performed and does not provide sufficient support for coverage of the testing. One of the 
required diagnosis codes were not submitted for these procedures. Therefore, without sufficient support 
provided in the sent documentation, this request for the above testing will be considered not medically 
necessary at this time. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on December 4, 2022, billed with procedure 
codes 95938, 95939, 95870 (x2) and G0453.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377) for an 
approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller. You say that this controller 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 and expandable controller is covered when 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 expandable controller. Our reviewer 
says that this feature is not medically necessary. Our physician reviewer found the records show the enrollee 
has sufficient strength to operate the standard controls for the power functions. 
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377) for an approved power 
wheelchair.