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

 
We decided that the Plan does not have to pay for the lab panel provided on December 1, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the testing is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes, and not one 
unit of one coe as required by LCA A58710. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on December 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 77387 performed on March 
7, 2023. 
 
You asked the Plan to pay for 77387. You say that 77837 should be paid at the full Medicare-allowed rate 
because it was medically necessary. The Plan denied your request. The Plan says 77837 is denied because no 
documentation was submitted by the provider on appeal to support this procedure was performed. 
 
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. We confirmed that the case file contains no medical records 
supporting 77387 was performed on March 7, 2023. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of 77387 have been met. 
Therefore, we decided that the Plan does not have to pay for the radiology services coded as 77387 performed 
on March 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 20936. The Plan denied your request. The Plan says procedure 
code 20936 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 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurosurgeon. 
 
You asked the Plan to pre-approve these services. You say that you have increased pain and numbness in your 
fingers and legs. The Plan denied your request. The Plan says the services are available from network 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network neurosurgeon.
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 is medically stable and does not need a physicians supervision 3 times a 
week in an IRF. There are no acute rehab nursing needs documented. At the current functional level of 
requiring only contact guard assistance, the enrollee does not need intensive therapies consisting of at least 3 
hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The complexity of 
the enrollees medical, rehab, and nursing needs (combined complexity) does not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
medical appointments. The Plan denied your request. The Plan says the requested trips exceed your 
transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
24-trip limit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for admission to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no required medical services identified that are available at the LTACH 
that are not available at the current health care setting being offered by the Plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. The documentation does not support that an additional 25 days of hospitalization are 
reasonably expected for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) direct skilled nursing services of a registered 
nurse (RN) in the home health or hospice setting visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration nd 
have submitted medical records for review. 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  The 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nine (9) direct skilled nursing services of a registered nurse (RN) in the home 
health or hospice setting visits (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) at L1 
(22514). 
 You asked the Plan to pre-approve PVA at L1. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific 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 PVA at L1. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding a diagnosis of osteoarthritis or undergoing treatment for such. Additionally, there is no 
documentation of a progression of the body height loss, greater than 25% vertebral body height loss, or 
kyphotic deformity. Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible 
causes of pain. Therefore, the enrollee does not meet the coverage criteria detailed in the 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 PVA at L1 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (PVA) at L1 (22514).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a lower extremity revascularization procedure (37221). 
 You asked the Plan to pre-approve a lower extremity revascularization procedure. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used 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 a lower extremity revascularization 
procedure. Our reviewer says that the services are medically necessary. Our physician reviewer found the 
documentation meets coverage criteria and supports the medical necessity of the procedure in question. The 
enrollee has severe, short distance claudication with computed tomography angiography (CTA) documented 
evidence of a right iliac artery occlusion. Claudication on the basis of severe iliac occlusive disease is 
particularly disabling. As there is satisfactory documentation of lifestyle limiting claudication and significant 
arterial disease coverage criteria are met and the plan for angiography and possible intervention reasonable and 
medically necessary. Based on the documented history, symptoms, and anatomy it is not likely that the enrollee 
would respond substantially with an exercise program. 
 
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 lower extremity revascularization procedure have been met. Therefore, we 
decided that the Plan has to pre-approve a lower extremity revascularization procedure (37221).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis and suspension sleeve 
provided on April 18, 2023. 
 
You asked the Plan to pay for the thoracic-lumbar-sacral orthosis and suspension sleeve. You say that the 
request is medically necessary for the enrollee. The Plan denied your request. The Plan says your request is not 
medically necessary because the enrollees records show they do not have a recent injury or surgery or 
objective evidence of instability. The enrollee did not have an appropriate face-to-face encounter, and there is 
no evidence that the provider ordered these braces or that the enrollee is even a patient of the provider. 
 
The Plan follows Medicare rules. Medicare rules say that 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 pay for the thoracic-lumbar-sacral orthosis and 
suspension sleeve. Our reviewer says that the items are not medically necessary. Our physician reviewer found 
that the documentation does not support subjective or objective exam findings supporting a need for the L0457 
spine orthosis. There is no evidence of recent injury/surgery to the knee. The documentation does not support 
that there was an in-person face to face exam and physical examination of the patient supporting the need for a 
knee immobilizer. The documentation indicates that the physician's office is 440 miles from the patient's home 
and that the physician's office confirmed the patient is not a patient of the physician.  
 
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 thoracic-lumbar-sacral orthosis and suspension sleeve have not been met. 
Therefore, we decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis and suspension 
sleeve provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker with bigger wheels. 
 
You asked the Plan to pre-approve a rollator walker with bigger wheels. You say that the requested rollator 
walker with bigger wheels is medically necessary because it will provide greater stability.  The Plan denied 
your request. The Plan says the requested rollator walker with bigger wheels is not medically necessary as the 
enrollee's needs can be met with the approved standard walker.  
 
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 a rollator walker with bigger wheels. 
Our reviewer says that the requested rollator walker with bigger wheels is not medically necessary as the 
enrollee's needs can be met with the approved standard walker.  Our physician reviewer found the medical 
progress note documentation does not support that the enrollee's functional needs are unable to be safely and effectively met with a standard walker. 
 
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 rollator walker with bigger wheels have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a rollator walker with bigger wheels.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
not a medical need to control approved power options through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a past medical history including central cord syndrome with resulting in 
paraplegia who has been authorized to have a group 3 power wheelchair. The enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. There is not a medical need for the upgraded electronics. Therefore, the requested electrical 
accessories are 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable control system.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says you do 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 documentation does not support necessity for admission to an IRF. The 
complexity of your medical, rehabilitation, and nursing needs does not require an acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be 
safely provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for care in an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving but is still somewhat unstable for transfer 
and requires additional acute care services that can safely be provided at the current facility until more stable 
and appropriate for a transfer. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.