Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 appealing with supporting records. 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee was admitted to the acute hospital on October 18, 2023, for mastectomy in the setting of 
breast cancer. She is now post-operative and is awaiting inpatient rehabilitation facility (IRF) placement. Her 
past medical history is also significant for diabetes, chronic right foot ulcer, congestive heart failure, and recent 
right humerus/radius fracture for which she is still non-weight bearing on that arm. Her level of function has 
been deteriorating in the setting of her cancer, but she is noted to have been previously independent. The 
treating team specifically recommended IRF placement to optimize strength, balance, mobility, activities of 
daily living independence, physician management of post-operative risks and of her various comorbidities, and 
ensure a safe return home. 
 
The enrollee's condition is complex and fragile, and there is reason to expect that she will participate in and 
benefit from IRF-level services to include at minimum PT, OT, physician oversight of wound care and 
polypharmacy, and case manager coordination of any additional services that might be needed to make a 
sustainable return, as well as avoid preventable readmissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 drug testing (G0482) provided on December 8, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says there is insufficient information in the records 
provided to support that the services performed were specifically requested by the enrollee's physician. 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 drug testing have been met. 
Specifically, the physician order provided does not clearly indicate which drugs are requested for testing in this 
case. Without this information, we cannot verify that the services provided were medically necessary and 
specifically requested by the enrollee's treating physician. Therefore, we decided that the Plan does not have to 
pay for drug testing (G0482) provided on December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 18, 2023, billed with 
codes 81432 and 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 18, 2023, billed with codes 81432 and 81433.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
needed for medical reasons. The Plan denied your request. The Plan says the requested neuropsychological 
testing does not meet the Medicare coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the 
criteria listed in the Medicare rules section of this decision 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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have a diagnosis of mild cognitive impairment with a 
family history of Alzheimer's disease. The provided medical records in this case do not clearly document that 
the testing is needed for any of the indications required by the Medicare LCD 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar ESI. 
 
You asked the Plan to pre-approve a lumbar ESI. You say that the enrollee needs the injection in order to 
improve their current condition. The Plan denied your request. The Plan says that the requested procedure does 
not meet the criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a lumbar ESI. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation provided shows that the enrollee meets all of the required LCD criteria for a 
lumbar ESI to be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar ESI have been met. Therefore, we decided that the Plan has to pre-
approve a lumbar ESI.  
 
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 thermal destruction of intraosseous basivertebral nerve 
(64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure addresses vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. You also 
say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. 
The Plan says this service 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease or stenosis. The cause of pain is not clear. Criteria is not 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (64628, 64629).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88341 billed for date of service June 1, 2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the billed number of units are not 
supported by the records as both provided and medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 18 units of this 
code, exceeding the MUE.  
 
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 88341. Our reviewer says that the services at 
issue in this case are supported by the medical records. Our reviewer found the enrollee underwent bladder 
transurethral resection for bladder tumor. This was a high-grade poorly differentiated malignant neoplasm. 
Immunohistochemical work up showing weak to moderate staining for TTF-1. Tumor cells also shows focal 
weak staining for CD 56.  Negative for pancyteokeratin, CK 5, CK 7, CK 20, HMB-45, Melan-A, Estrogen 
Receptor, S-100, CDX-2, Synaptophysin, Chromogranin, CA-125, GATA 3, Monoclonal CEA, p63, p40. 
Given the confusing pathology not typical for high grade urothelial carcinoma and the possibility of metastasis 
from a non-bladder primary tumor, the additional immunohistochemistry is justified. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 88341 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 88341 billed for date of service June 1, 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: 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 reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF 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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status.  The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies provided on July 6, 2023.  
 
You asked the Plan to pay for incontinence supplies. You say that you would like reconsideration because the 
requested incontinence supplies are medically necessary. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on 
July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 18, 2023, billed with 
codes 87481, 87651, 87640, 87653, 87801 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 18, 2023, billed with codes 87481, 87651, 87640, 87653, 87801 and 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy, flexible; with biopsy, single or multiple 
(45380). 
 
You asked the Plan to pre-approve the colonoscopy with biopsy. You say that you only schedule for a 
screening and not anything more. The Plan denied your request. The Plan says a screening colonoscopy was 
already approved. The Plan also says that an additional colonoscopy cannot be approved. 
 
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 colonoscopy with biopsy. Our reviewer says that the requested colonoscopy with biopsy is not considered medically reasonable and necessary 
in this case. Our physician reviewer found the provided documentation indicates that the colonoscopy which 
the Plan approved is the most appropriate by itself. Therefore, the reviewer found that an additional 
colonoscopy is 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 the colonoscopy with biopsy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a colonoscopy, flexible; with biopsy, single or multiple (45380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, with 
mattress (E0303). 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the enrollee is 62 with a history of 
stroke and left sided weakness and cannot be positioned with just pillows alone. He cannot be maneuvered 
easily in a regular size bed and needs positional changes. The Plan denied your request. The Plan says the 
enrollee does not meet coverage criteria for a heavy duty extra wide hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds but does not exceed 600 pounds. 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty hospital bed have not been met. Specifically, the records show the enrollee's current 
weight is 224 pounds, therefore, the enrollee does not meet criteria for approval of a heavy-duty hospital bed. 
Therefore, we decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with 
weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, with 
mattress (E0303).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) at L2-L3. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary to treat the 
enrollee's pain. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that that thermal destruction of the intraosseous 
basivertebral nerve (BVN) will be considered medically reasonable and necessary for the treatment of chronic 
low back pain (cLBP) in patients who meet all the criteria. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
provided documentation does not show a clear cause of the enrollee's pain. The reviewer found that magnetic 
resonance imaging (MRI) shows more than Modic changes with degenerative joint disease. The reviewer also 
found that the Intracept procedure is considered experimental. Therefore, the reviewer found that the requested 
Intracept procedure is 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) at 
L2-L3.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 appealing the denial. 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission (as best summarized by the physical and occupational therapy (PT/OT) notes from October 24). This 
enrollee's condition is complex and fragile, given his advanced age and prolonged period of decreased mobility 
leading up to this admission. There is reason to expect that he will participate in and benefit from IRF-level 
services to include at minimum PT, OT, physician oversight of polypharmacy, and case manager coordination 
of any additional services that might be needed to make a sustainable return, as well as avoid preventable 
readmissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.