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

 
We decided that the Plan does not have to pay for one additional unit of procedure code 87798 rendered on 
November 23, 2022. 
 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 additional medical records to support the additional services were unable to be obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 documentation does not 
clearly state that the additional unit was rendered in this case, and there is no clear documentation as to why 
these additional units were necessary. 
 
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 one additional unit of procedure code 87798 rendered on November 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on April 6, 2023. 
 You asked the Plan to pay for the services. You say that the plan's statements are incorrect. The Plan denied 
your request. The Plan says Medicare says screening services performed for a purpose other than treatment or 
diagnosis of a specific illness, symptoms, complaint, or injury are excluded from coverage. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review indicates that the enrollee had a diagnosis of encounter for screening for other viral 
diseases. The services were not authorized because, they are not a Medicare benefit for the diagnoses listed on 
the claim and were done for screening purposes. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services rendered on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87798, 87653, 87640, 87511 and 
87481) provided on March 8, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel (87798, 87653, 87640, 87511 and 87481) provided on March 8, 2023.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to pay for J1100. We decided that the Plan does not have to pay for Q9966.  
 You asked the Plan to pay for procedure codes J1100 and Q9966 rendered on June 7, 2022.. You say that  The 
Plan says that  
 
We decided that the Plan has to pay for J1100.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The plan's denial for J1100 is unreasonable and unsubstantiated. The plan has paid for the epidural steroid 
injection, but denied J1100 has experimental and investigational. The applicable guidelines for these injections 
state that up to 15mg of dexamethasone is appropriate for epidural steroid injections. The CPT definition of 
J1100 is "Injection, dexamethasone sodium phosphate, 1 mg." 15 units of this code was billed. As the code 
allows for 1mg of dexamethasone sodium phosphate, 15 units would be equivalent to 15mg. This is 
appropriate. Therefore, we decided that the Plan has to pay for J1100.  
 
We also decided that the Plan does not have to pay for Q9966. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
Healthcare Common Procedure Coding System (HCPCS) Q9966 - low osmolar contrast material, 200-299 
mg/ml iodine concentration, per ml - was reported alongside CPT 62323 and HCPCS J1100. This code is 
excluded, and does not have any defined payment amounts. It should not reported separately. Therefore, we 
decided that the Plan does not have to pay for Q9966. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test indicates an inadequate response to 
therapy. The Plan denied your request. The Plan says the clinical value has not been demonstrated. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. For molecular diagnostic tests, such as the test at issue, the MolDX program 
requires tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. 
The PrismRA test at issue has not demonstrated analytical and clinical utility to be considered reasonable and 
necessary. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service February 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (J7327). 
 
You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says the enrollee's 
diagnosis is not indicated for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Monovisc. Our reviewer says that 
Monovisc is not reasonable or necessary for the enrollee. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of meniscal tear. The FDA has not stated that the requested drug is indicated 
for the enrollee's condition. Our reviewer found that the Medicare approved 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. Our physician reviewer also found that 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (J7327).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional power wheelchair accessories (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 accessories. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is non-ambulatory and requires a power wheelchair for mobility and performing his 
basic daily activities. The enrollee cannot perform pressure relief independently due to upper extremity 
weakness and requires a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. The enrollee currently has gluteal pressure wounds. The enrollee requires power elevating leg rests 
for positioning of the lower extremities and lower extremity edema. The complexity of the enrollee's seating 
and positioning needs necessitates a more complex group 3 power wheelchair base. The expandable controller 
with harness and electronic connection are necessary to operate the group 3 power wheelchair base and the 
three power options via a joystick. These components are required to operate 3 or more power options on a 
group 3 power wheelchair. 
 
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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve additional power wheelchair accessories (E2311, E2313, E2377).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, single-photon emission 
computerized tomography (SPECT) scan (78452), cardiovascular stress test (93015), Technetium tc-99m 
sestamibi (A9500), and adenosine injection (J0153). 
 
You asked the Plan to pre-approve a myocardial perfusion imaging, SPECT scan, cardiovascular stress test, 
Technetium tc-99m sestamibi, and adenosine injection. The Plan denied your request. The Plan says no 
additional clinical notes were submitted to substantiate medical necessity. 
 
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 myocardial perfusion imaging, 
SPECT scan, cardiovascular stress test, Technetium tc-99m sestamibi, and adenosine injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have no documented physical limitation for performing a treadmill exercise 
stress test. Our reviewer also found that there is no documentation of baseline electrocardiogram abnormalities 
to prevent proper interpretation of the interval between depolarization and repolarization of the ventricles. 
 
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 myocardial perfusion imaging, SPECT scan, cardiovascular stress test, 
Technetium tc-99m sestamibi, and adenosine injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a myocardial perfusion imaging, single-photon emission computerized 
tomography (SPECT) scan (78452), cardiovascular stress test (93015), Technetium tc-99m sestamibi (A9500), 
and adenosine injection (J0153).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
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 for the enrollee 
to receive the services needed. 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 enrollee does 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 pre-approve Percutaneous Tibial Nerve Stimulation (PTNS). 
 
You asked the Plan to pre-approve PTNS. You say that PTNS is medically necessary. The Plan denied your 
request. The Plan says the requested PTNS is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PTNS. Our reviewer says that the 
requested PTNS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee with frequent urinary tract infections, urinary retention managed with intermittent self- 
catheterization and urge incontinence managed with pads. The enrollee has a history of vaginal prolapse treated 
with cystocele, enterocele and rectocele repair on January 17, 2023. The enrollee also underwent vaginal 
colpopexy sacrospinous and cystoscopy on December 22, 2022. the records indicate that the enrollee may have bladder outlet obstruction and has not tried behavior modification or medical therapy. Percutaneous tibial nerve 
stimulation (PTNS) is a technique of electrical neuromodulation used primarily for the treatment of voiding 
dysfunction in patients who have failed behavioral therapies and/or pharmacologic therapies. Voiding 
dysfunction includes urinary frequency, urgency, incontinence and nonobstructive retention. Common causes 
of non-neurogenic voiding dysfunction are pelvic floor neuromuscular changes (from pregnancy, childbirth, 
surgery, etc.), inflammation, medication side effects (e.g., diuretics and anticholinergics), obesity, and 
psychogenic factors. Overactive bladder is a non-neurogenic voiding dysfunction characterized by urinary 
frequency, urgency, urge incontinence, and nonobstructive retention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve PTNS.
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 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 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: 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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for approval of SNF have not been met. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
November 15, 2022. 
 
You asked the Plan to pay for the services. You say that this test is a Medicare-covered service that is 
performed in the clinical laboratory ordered by a treating physician who makes the professional determination 
of diagnosis and medical necessity to successfully treat their patients. The Plan denied your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical 
management, exceeds the needs of the enrollee. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a history of depression, anxiety, schizophrenia, opioid dependence who is being 
treated with medication assisted treatment using buprenorphine had extensive definitive toxicology testing. The 
documentation does not support that testing for 22+ drug classes was 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) rendered on November 15, 2022.