Persius/hicric huggingface dataset:
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies as an 
outpatient or at a skilled nursing facility (SNF) may be approved upon request.  
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab 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. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement. However, the documentation doesnt 
support that they would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least three visits weekly to regain or maintain his 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mycophenolate. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that the self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve mycophenolate.  
 
Benefits for the drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 88291, 88368, 88369, 
88377, and G0452) rendered on July 7, 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 the denied codes is: 
 
CPT 88291: 
 
Cytogenetics and molecular cytogenetics, interpretation and report 
 
CPT 88368: 
 
Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial 
single probe stain procedure 
 
CPT 88369: 
 
Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each 
additional single probe stain procedure (List separately in addition to code for primary procedure) 
 
CPT 88377: 
 
Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each 
multiplex probe stain procedure 
 
Healthcare Common Procedure Coding System (HCPCS) G0452: 
 
Molecular pathology procedure; physician interpretation and report 
 
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 the provider reported these 
procedure codes with appended modifier XU. The laboratory report does not include documentation to support 
that any unusual or non-overlapping service was performed. The codes and the modifier XU 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 laboratory services (procedure code 88291, 88368, 88369, 88377, and G0452) rendered on July 
7, 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 says that she is high level functionally 
and independent prior and wants to be recovered before she gets back home and needs impatient rehabilitation 
and does not have anyone to help her care for her at home and is very eager to be fully recovered. 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 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 
was admitted for surgical repair of a hip fracture after a fall. There are no complex nursing or rehabilitation 
needs. 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 the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20680-XS-LT rendered on June 23, 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 documentation does not support the separate reporting of CPT 20680. 
 
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 20680 is "Removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate)."  
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 the operative report describes a 
removal of deep implant performed in separate incision as femoral fracture treatment; however, the removal of 
the deep implant is still considered integral from the primary procedure and would not be separately reported.  
 
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 procedure code 20680-XS-LT rendered on June 23, 2023.
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 you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the SNF services you are requesting 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 4, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomy of varicose veins. 
 
You asked the Plan to pre-approve the stab phlebectomy of varicose veins. The Plan denied your request. The 
Plan says that the stab phlebectomy of varicose veins is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that slab phlebectomy services are covered when 
medically necessary and when certain criteria have been 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 the stab phlebectomy of varicose veins. 
Our reviewer says that the stab phlebectomy of varicose veins is not medically necessary. Our physician 
reviewer found that the records show that treatment will be aimed at spider veins and a varicose vein in the 
upper thigh. There is no documentation of a recent imaging study (duplex scan) having been received to 
confirm that the vein was 3 millimeters (mm) or larger in diameter, or to confirm that there is still reflux 
present. There is insufficient documentation to support the medical necessity for the requested slab 
phlebectomy in this enrollees clinical management.  
 
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 stab phlebectomy of varicose veins have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the stab phlebectomy of varicose veins.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve a PET scan. You say that a PET scan is medically necessary. The Plan 
denied your request. The Plan says the Medicare criteria for coverage has not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the requested PET scan is not considered medically necessary in this case. Our physician reviewer found that 
the enrollee has gait disturbance and a DaTscan is requested to rule out Parkinsonism. The record provided 
does not establish that the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal 
dementia or that the examination is being requested in the context of a clinical trial. The elements of the 
coverage criteria are not satisfied.  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that the requested services are 
experimental/investigational for the enrollee's condition. 
 
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 IMRT. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that IMRT is within the standard of care to treat the hand and regional lymphatic (up to the axilla). The 
enrollee cannot be treated safely and effectively without IMRT. IMRT would 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 IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity-modulated radiation therapy (IMRT).  
 
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 pre-approve a topical hyperbaric oxygen chamber. 
 
You asked the Plan to pre-approve the requested service. You say that the enrollee has been receiving a 
standard wound care regimen with little to no progress. The Plan denied your request. The Plan says there is 
insufficient data to show the effectiveness of this treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We looked at the file, and Medicare rules. Topical hyperbaric oxygen chambers are not reasonable and 
necessary. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a topical hyperbaric oxygen chamber.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services rendered from December 15, 
2021, to December 19, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment coding validation 
audit was performed to ensure that the diagnosis codes on the claim were supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 190. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented to the emergency department (ED) with respiratory symptoms and a known sick 
contact.  Radiographs showed pneumonia.  The enrollee was admitted and treated for the same.  It appears that 
the principal diagnosis was pneumonia, not chronic obstructive pulmonary (COPD), COPD with infection or 
COPD with exacerbation.  As such, the billing of J44.0 as the principal diagnosis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from December 15, 2021, to December 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient facility room (41899) and the anesthesia 
(00170) to be covered under medical benefits. 
 
You asked the Plan to pre-approve the dental services. You say that because of your medical condition you 
need the procedures done in a hospital setting. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because any hospital, surgical or treatment facility, or for services of 
an anesthesiologist or anesthetist are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The requested outpatient facility room and the anesthesia in dispute meets the Medicare definition of dental, 
since it is a service which involved the care and treatment of teeth or structures directly supporting the teeth. 
The outpatient facility room and the anesthesia do not fall under any of Medicare exceptions for coverage of 
non-routine dental care. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested 
items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve the outpatient facility room (41899) and the anesthesia (00170) to be covered under 
medical benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 15275, 15276, and Q4262 rendered on May 
24, 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 denied codes remain 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 the denied codes is: 
 
CPT 15275: 
 
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area 
 
CPT 15276: 
 
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, 
and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, 
or part thereof (List separately in addition to code for primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) Q4262: 
 
Dual layer impax membrane, per square centimeter 
 
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 the medical records do not 
include sufficient documentation to validate that the denied codes were performed on May 24, 2023. The 
medical records indicate a skin substitute graft was applied to the left leg which does not fit the description of 
the CPT code 15275 billed, therefore this service cannot be verified. In terms of CPT 15276, this code is an 
add-on code which requires a primary code. The primary code billed (15725) could not be verified and was not 
eligible for reimbursement, therefore 15276 is not eligible for reimbursement. The records also do not support 
that dual layer impax membrane, per square centimeter (65 units) was performed; therefore, Q4262 is not 
supported. 
 
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 procedure codes 15275, 15276, and Q4262 rendered on May 24, 2023.