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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for pulmonary embolism and cardiac arrest. Medical 
problems are stable. 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 this 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 7, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel and lodging expenses provided September 30, 2022. 
 
You asked the Plan to pay for travel and lodging expenses. You say that the procedure was performed on 
September 20 with a 5am check in. This required you to travel on the 19th and spend the night. Since this was a 
pre-approved procedure, deemed medically necessary, your travel expenses should be covered. The Plan 
denied your request. The Plan says travel expenses is not covered under the Plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 
 
You are requesting reimbursement for travel and lodging expenses. The records indicate that the Plan did 
approve an upper gastrointestinal endoscopy procedure, but the prior authorization did not include or reference 
travel expenses. The provided records also did not include a receipt for the cost incurred or proof of payment 
for the requested travel or lodging expenses. However, the Plan does not offer a benefit for travel and lodging expenses. Therefore, we decided that the Plan does not have to pay for travel and lodging expenses provided 
September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre kit. 
 
You asked the Plan to pre-approve a Freestyle Libre kit. You say that the requested Freestyle Libre kit is 
medically necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an  
 in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre kit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injection, etanercept, 25 mg. 
 
You asked the Plan to pre-approve Injection, etanercept, 25 mg. The Plan denied your request. The Plan says 
this is part of the self-administered drug exclusion list. 
 
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 Injection, etanercept, 25 
mg.  
 
Benefits for Injection, etanercept, 25 mg 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 SelectMDx testing (0339U) provided on December 20, 2022. 
 
You asked the Plan to pay for SelectMDx testing. You say that this test should be covered. The Plan denied 
your request. The Plan says this test has not met criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that the tests listed in the LCA have met coverage 
criteria. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx testing have not been met. Specifically, this test is not listed to meet criteria for 
approval in the LCA. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (0339U) 
provided on December 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Provigil tablet. 
 
You asked the Plan to pre-approve Provigil. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Provigil 
tablet.  
 
Benefits for Provigil 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous neuromodulation therapy (PNT) using a 
Sprint PNS device (64555, L8680). 
 
You asked the Plan to pre-approve a PNS device. You say that the enrollee's pain can be managed with PNS. 
The Plan denied your request. The Plan says peripheral nerve stimulator systems are not allowed, are unproven 
and not medically necessary. Implantation of electrodes requires surgery and usually necessitates an operating 
room. 
 
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 PNS device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back and hip pain. She has had physical therapy, a home exercise 
program, and over the counter medications. There are ongoing clinical trials of the Sprint PNS for enrollees 
with low back pain. The enrollee is not enrolled in a clinical trial. Therefore, the request is deemed not 
medically reasonable and 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 a PNS device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous neuromodulation therapy (PNT) using a Sprint PNS device (64555, L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for X-ray services (71046) as well as transport (R0070) and set-
up (Q0092) of portable X-ray equipment provided on October 25, 2022. 
 
You asked the Plan to pay for X-ray services and transport and set-up of X-ray equipment. You say that the 
services at issue have been billed correctly. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that radiology and other diagnostic services furnished 
to hospital outpatients are paid under the OPPS to the hospital. The rules also say that POS code 31 should be 
used with services for patients in a Part A covered stay and POS code 32 should be used with services for 
beneficiaries in noncovered stay. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of X-ray services have not been met. Specifically, the records suggest that these services were 
rendered in a long-term skilled nursing facility. Procedure code 71046 has a professional/technical component 
indicator of 1. This means that this code has a professional and technical component. This code has not been 
billed with the appropriate modifier to indicate that it is for the professional component. Payment for the 
technical component of this code is included in the payment to the facility and is the responsibility of the 
facility to any vendor. 
 
Furthermore, we found that Medicare rules for transport and set-up of X-ray equipment have not been met. 
Specifically, review of the file shows that the enrollee resides in a senior living community, which is not 
covered by Part A Medicare. The provider billed place of service 31 and the Medicare rules state that POS code 
31 should be used with services for patients in a Part A covered stay. Therefore, POS code 32 should be used 
with services for beneficiaries in noncovered stay. Therefore, we decided that the Plan does not have to pay for 
X-ray services (71046) as well as transport (R0070) and set-up (Q0092) of portable X-ray equipment provided 
on October 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of an IUD (code 58300) provided on  
November 14, 2022. 
 
You asked the Plan to pay for insertion of an IUD. You say that insertion of an IUD was medically necessary. 
The Plan denied your request. The Plan says the insertion of an IUD is not a covered benefit. Per Medicare 
regulations, contraceptive devices or medications are not allowed for payment. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
insertion of an IUD (code 58300) provided on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that any potential benefit or detriment of proton beam radiation therapy over 
standard intensity-modulated radiation therapy (IMRT) is an investigational question. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77523).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as U0004, G2024, U0005 
provided March 9, 2021, to March 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the claims were received after the 
timely filing limitation. 
 
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 December 13, 2022, and December 
16, 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 coded as U0004, 
G2024, U0005 provided March 9, 2021, to March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy services. 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that, based on community standards of care, the basal cell carcinoma on the upper lip 
does not require brachytherapy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital and laboratory services provided 
October 20, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that you had originally submitted the claim to 
another carrier before discovering the enrollee had this Plan as primary. You are asking for reprocessing of this 
claim for total expected reimbursement due of $734.00 per your contracted rates. The Plan denied your request. 
The Plan says the claim was not received until after the timely filing limitation. 
 
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 outpatient services was not filed until December 15, 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 outpatient hospital and laboratory services provided October 
20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an initial observation care, per day, for the evaluation and 
management of a patient provided on September 23, 2022, billed with procedure code 99220. 
 
You asked the Plan to pay for the initial observation. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says current procedural terminology (CPT) code 99220 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99220 is Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We asked our physician 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 initial observation. Our reviewer says that the 
documentation does not support procedure code 99220. Our reviewer found that the medical decision making 
was not of high complexity.   
 
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 initial observation have not been met. Therefore, we decided that the Plan 
does not have to pay for an initial observation care, per day, for the evaluation and management of a patient 
provided on September 23, 2022, billed with procedure code 99220.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the services of home health/hospice aide (G0156). 
 
You asked the Plan to pre-approve the aide services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found there is no evidence that you currently have skilled nursing needs. There is no evidence that you currently have skilled therapy 
needs. There is no evidence that the services of a home health aide (HHA) are currently required to assist in the 
treatment of an acute illness or injury. As such, the request for HHA services is not medically necessary or 
reasonable. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the services of home health/hospice aide (G0156).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81479) provided on June 22, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (81479) 
provided on June 22, 2022.