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 you cannot go to a skilled nursing facility because 
you are completely immobilized and a skilled nursing facility cannot assist in helping you get better. The Plan 
denied your request. The Plan says an IRF admission 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for hypoglycemia and was discharged home on 11/18/23 where there is ongoing fatigue. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sedation services for a facet joint injection. 
 
You asked the Plan to pre-approve sedation services for a facet joint injection. You say that the injections are 
painful, and it can be difficult for the enrollee to remain still. The Plan denied your request. The Plan says the 
requested service is not medically necessary and reasonable. 
 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 sedation services for a facet joint 
injection. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, there is no specific indication for the 
requested sedation. The review has determined that the items/services at issue in this case are not medically 
reasonable and necessary. The enrollee does not meet the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sedation with facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sedation services for a facet joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on May 8, 2023. 
 
You asked the Plan to pay for the back brace. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records provided do not show that the enrollee was evaluated for a back problem. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the back brace provided on May 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary to monitor 
your nodule. The Plan denied your request. The Plan says you do not meet the criteria for the CT scan at this 
time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found you have a stable nonmetabolic pulmonary 
nodule with calcification and serial imaging is appropriate but not specialty or additional scans. There is no 
indication for additional imaging 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the chest.
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 services are medically necessary as you need 
long term care services to prevent an infection. The Plan denied your request. The Plan says the services that 
you need can be provided in an alternate setting.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99235) provided on July 17, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 29823 
provided on July 17, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the services (99235) provided on 
July 17, 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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria 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 the enrollee does not require the intensity of services provided at an IRF. The 
enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollees care needs can be met 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until July 7, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided June 
27, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that please see attached medical 
records. The Plan denied your request. The Plan says the records do not support that the enrollee meets the 
criteria. 
 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. The record does not show a diagnosis of psoriasis. There is no 
indication of intractable psoriasis, as there is no indication the enrollee has failed other treatments for psoriasis. 
There are also no other factors described that would justify treatment at home rather than alternative sites, like 
a clinic or the hospital. The Plan also confirmed with the ordering provider indicated that they did not order this 
item or refer the enrollee to this supplier. Based on this information, we decided that Medicare rules for 
coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does 
not have to pay for the ultraviolet light therapy system (E0691) provided June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided June 15, 
2023, to June 20, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you were told that if you 
got the laboratory services done at your doctor's office, there would be no charge. 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 $25 
copayment for Medicare-covered lab services. 
 
You have been asked to pay $49.52 (25.00 + 24.52) for the laboratory services. For date of service June 15, 
2023, the allowed amount was less than the copayment amount, so you are responsible for the lesser amount. This item/service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 the laboratory services provided June 15, 2023, 
to June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genomic Unity Comprehensive Analysis testing.  
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the test is not approved for coverage. 
 
The Plan must follow Medicare rules. The rules say that molecular pathology is covered when specific criteria 
are met. 
 
We looked at the file and Medicare rules. The file shows that the requested test is not approved by the Food 
and Drug Administration (FDA) and has not completed a Technical Assessment (TA) by the Molecular 
Diagnostic Services Program. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve Genomic Unity 
Comprehensive Analysis testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, 
other than spinal applications (E0747). 
 You asked the Plan to pre-approve an osteogenesis stimulator. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
stimulator. 
 
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 osteogenesis stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there has not been enough time that has passed for nonunion to be established. The 
enrollee needs at least 9 months of fracture healing. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, other than spinal 
applications (E0747).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is medically necessary to treat 
the enrollee's diagnosis. The Plan denied your request. The Plan says the requested drug does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 Keytruda. Our reviewer says that the 
requested drug does not meet the necessary criteria to be approved. Our physician reviewer found that the 
record indicates that the enrollee has a diagnosis of metastatic recurrent urothelial carcinoma. The provided 
record does not document that the enrollee's condition is one for which coverage is available under the 
rules. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot 
be 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing (81479) provided on August 11, 
2023. 
 
You asked the Plan to pay for Guardant Reveal. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant Reveal testing (81479) provided on August 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism purchased on June 21, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the seat 
lift mechanism purchased on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 27, 2023, billed 
with procedure code 99214. 
 
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 claim was billed with an invalid procedure 
code. 
 
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 the practitioner services provided have 
been met. Specifically, no medical records have been provided for review. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on January 27, 2023, billed with procedure code 99214.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 28, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service April 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service October 8, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says procedure code 36000 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service October 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that you need this exam. The Plan denied your 
request. The Plan says dental services from an out-of-network provider are not covered by your supplemental 
benefits.  
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150).