Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (87631, 87541, 87486) provided May 30, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services should not be denied as they 
were requested by qualified physicians. The Plan denied your request. The Plan says that the requested service 
is considering to be experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had symptoms of infection and the best practice is to send the laboratory studies to 
determine organism and improved antibiotic targeted therapy. The enrollee's diagnostic studies are not 
experimental or investigation, but rather standard 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 the laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the laboratory services (87631, 87541, 87486) provided May 30, 2023.  
 
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 pre-approve a group 2 standard power wheelchair (K0821) and 
additional items and accessories (codes K0733 x2, E0973 x2, and E1028). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says this request is not medically necessary because the records show 
the enrollee is able to safely use a scooter and a scooter will fit in their home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 group 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee appears to be functionally non-ambulatory and cannot use a cane or 
walker for mobility due to joint pain and difficulty ambulating. They may not be able to functionally propel a 
manual wheelchair due to upper extremity joint pain. Our reviewer found that the enrollee may require a power 
mobility device. However, the documentation does not indicate why the enrollee cannot use a group 1 power 
mobility device. The enrollee is limited with ambulation but is still modified independent with mobility and can 
independently perform transfers. Our physician reviewer also found that the enrollee has 4 out of 5 motor 
strength in the upper and lower extremities. 
 
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 group 2 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0821) and additional items and accessories (codes K0733 x2, E0973 x2, and E1028).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight portable motorized/power wheelchair 
(K0012). 
 
You asked the Plan to pre-approve a lightweight portable motorized/power wheelchair. You say that you do not 
have the income to purchase a power wheelchair, nor can you push yourself without assistance due to 
disability. The Plan denied your request. The Plan says based on medical records received, you were able to 
complete MRADLs with no assistive devices. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 lightweight portable motorized/power 
wheelchair. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found 
you have a mobility deficit. The documentation states the functional mobility cannot be resolved by a manual 
wheelchair, walker, or cane as you are able to perform MRADLS slowly at home with little help. Our reviewer 
found that the documentation does not reveal a home assessment supporting that the requested wheelchair can 
maneuver safely within the home. Our physician reviewer also found that the requested K0012 is 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 a lightweight portable motorized/power wheelchair have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lightweight portable motorized/power 
wheelchair (K0012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99001 billed for date of service December 
21, 2022. 
 
You asked the Plan to pay for procedure code 99001. You say that the services should be paid as billed.  The 
Plan denied your request. The Plan says procedure code 99001 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 99001 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99001 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99001 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99001 billed for date of service December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95937, 95861) provided on August 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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. 
 
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 use of codes 95937 
and 95861 is not supported by the records provided. Our reviewer found that the record states that train of four 
testing was performed. According to CPT rules, this is included in intraoperative neuromonitoring and cannot 
be separately reported with 95937. For code 95861, there is no documentation supporting that needle 
electromyography (EMG) of two extremities was performed during this encounter. 
 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 the services (95937, 95861) provided on August 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 36620 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for code 36620. You say that code 36620 is a covered service. The Plan denied your 
request. The Plan says the medical records do not support the billing of code 36620. 
 
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 36620 is Arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure. 
 
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 code 36620. Our reviewer says that code 36620 is not 
supported by the medical record. Our reviewer found there is no documentation of arterial catheterization for 
sampling, monitoring, or transfusion.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 36620 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 36620 billed for date of service May 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets the long-
term acute care admission criteria. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer 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 the enrollee was admitted from an LTACH facility following a fall and found to have 
a subdural hemorrhage. The record indicates that the enrollee is improving but still requires acute care services 
before transitioning to a lower level of care. Our reviewer found that the enrollee continues to receive acute 
care services, and these have not been denied. Our physician reviewer also found that the medical record does 
not indicate that the enrollee requires services that they are not currently receiving but that would be available 
at the LTACH 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 long term acute care hospital (LTACH) 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 all parties agree the patient is suitable for an 
inpatient rehabilitation admission. You also say that the supporting evidence provided highlights the medical 
necessity and potential benefits for this level of care, aiming to optimize the patient's overall health outcomes. 
The Plan denied your request. The Plan says based on the available information, admission to an IRF is not 
reasonable and 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 can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. Our reviewer also found that there is 
documentation that there is 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, but the services required can be 
provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a regimen of Darzalex Faspro, Velcade, and 
dexamethasone sodium phosphate. 
 
You asked the Plan to pre-approve Darzalex Faspro, Velcade, and dexamethasone. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says there is no support for this 
regimen. 
 
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 Darzalex Faspro, Velcade, and 
dexamethasone. Our reviewer says that the enrollee does not meet criteria for the requested drug combination. Our physician reviewer found the requested combination is not Food & Drug Administration (FDA) approved 
for the enrollee's diagnosis. This combination use is not supported by one of the major drug compendia or by 
clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro, Velcade, and dexamethasone have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a regimen of Darzalex Faspro, Velcade, and 
dexamethasone sodium phosphate.
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 admission is medically necessary for additional 
hours of physical therapy verses a skilled nursing facility. The Plan denied your request. The Plan says the 
enrollee's records do not show that your rehabilitation needs are complex. The Plan says services may be 
provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation to get back to their 
baseline. They do not have adequate care or help at home to support their recovery. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on April 11, 2023, billed with codes 
95870, 95938, G0453, and 95937. 
 
You asked the Plan to pay for the testing. You say that codes 95870, 95938, G0453, and 95937 were billed 
correctly and should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes 
cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.2 has an Excludes1 note in relation to M50.322. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing provided on April 11, 2023, billed with codes 95870, 95938, G0453, and 95937.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rybelsus. 
 
You asked the Plan to pre-approve the medication. You say that this drug is medically necessary for treating 
type 2 diabetes mellitus with hyperglycemia. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 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 Rybelsus.  
 
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has attempted a number of other 
medications with no relief. You say this medication could potentially address symptoms within 14 days. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 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 Xifaxan.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.