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 enrollee clearly meets both medical necessity and 
functional necessity for admission to inpatient rehabilitation. The Plan denied your request. The Plan says the 
IRF services requested 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 enrollee does not require and is not able to participate in intensive rehabilitation. 
The enrollee does not have complex needs and is non-weight bearing. The enrollee cannot use a prosthesis and 
needs to regain strength to improve bed mobility, transfers, and ambulation. These are common post-acute 
rehabilitation needs, not complex or intensive needs, and do not require frequent physiatry oversight. The 
enrollee's functional status can be addressed at the skilled nursing facility or home care level.  
 
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 mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 72 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 130 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF)-based physical therapy services 
provided from November 19, 2021, to November 30, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that these services were prior authorized 
and were billed correctly.  The Plan denied your request. The Plan says that you did not bill two ancillary 
rehabilitation therapy revenue codes on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that when a HIPPS rate code of RUAxx, RUBxx , 
RUCxx, RULxx and/or RUXxx is present, a minimum of two rehabilitation therapy ancillary codes are 
required (revenue code 042x and/or, 043x and/or, 044x). When a HIPPS rate code of RHAxx, RHBxx, RHCxx, 
RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx, RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RVBxx, 
RVCxx, RVLxx, and/or RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue code is 
required (revenue code 042x, 043x, or 044x. Bills that are missing required rehabilitation therapy ancillary 
revenue codes are to be returned to the SNF for resubmission. 
 
In this case, the Plan's sole rationale for denial is that you did not bill this claim with two ancillary 
rehabilitation therapy revenue codes.  This is not true.  The claim form (both paper and electronic) clearly 
states that two separate and distinct rehabilitation therapy revenue codes (0420 and 0424) were billed.  The 
Plan has provided no other support for its denial, and it has failed to address the billing of these two separate 
codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have been met. Therefore, we decided that the Plan has to pay for the 
skilled nursing facility (SNF)-based physical therapy services provided from November 19, 2021, to November 
30, 2021.  
 
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 reduce the cost share for the tissue pathology services provided from 
January 4, 2023, to January 5, 2023. 
 
You asked the Plan to reduce the cost share for the tissue pathology services. You say that the sample was 
taken and arrived at the lab in 2022 but was delayed due to the holiday schedule. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the also Plan says that you must pay a $0 copayment after meeting the 
deductible for outpatient lab services. 
 The item or service you asked the Plan to reduce the cost share for falls within the outpatient diagnostic tests 
and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $300 deductible which applies to outpatient diagnostic tests and therapeutic services. 
This cost sharing is a contractual obligation that had not been met at the time the tissue pathology services were 
received from January 4, 2023, to January 5, 2023. Therefore, we decided that the Plan does not have to reduce 
the cost share for the tissue pathology services provided from January 4, 2023, to January 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is functioning at a level satisfactorily managed at the skilled nursing 
facility or home care level, per evidence based and clinical practice standards. The enrollee does not require 
complex or intensive rehabilitation services and does not require frequent physiatry oversight.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says a power scooter is not medically necessary. 
 
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 power scooter. Our reviewer says that 
the requested power scooter is not medically necessary Our physician reviewer found the documentation available for review does not support that you require a power mobility device to accomplish mobility related 
self-care tasks in the home. There is no indication you are unable to use an alternative assistive device. 
Therefore, the reviewer found that the requested power scooter is not medically reasonable or 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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on April 13, 
2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on April 13, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) device 
(64555). 
   
You asked the Plan to pre-approve the SPRINT PNS device. You say that this is medically necessary. The Plan 
denied your request. The Plan says as the SPRINT PNS device request is not for a trial for a permanently 
implanted device and a review of full-text clinical studies, clinical practice guidelines, and position statements 
suggest no or unclear support for using SPRINT PNS for chronic pain, the requested device is not reasonable 
and medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of stimulators can be covered under 
specific 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 the SPRINT PNS device. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no evidence-based 
support for this request. 
 
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 SPRINT PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) device (64555).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on February 22, 
2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or cleared indication for use in this enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Tempus xF testing (81455) provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve D5225. The Plan has failed to provide evidence to show that 
D5225 was previously provided and paid. We decided that the Plan does not have to pre-approve 
D6245/D6740 for teeth #19 and #20.  
 You asked the Plan to pre-approve pontics (D6245) and retainer crowns (D6740) for teeth #19 and #20, and a 
maxillary partial denture (D5225). You say that this dental work is all medically necessary. The Plan says that 
the requested services have already been exhausted. 
 
We decided that the Plan has to pre-approve D5225.  
 
The Plan has failed to provide evidence to show that D5225 was previously provided and paid. Therefore, we 
decided that the Plan has to pre-approve D5225.  
 
We also decided that the Plan does not have to pre-approve D6245/D6740 for teeth #19 and #20. 
 
The Plan has approved D6245/D6740 for teeth # 11, #12, #13, and #18. Therefore, we decided that the Plan 
does not have to pre-approve D6245/D6740 for teeth #19 and #20. 
 
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 code G0483 for date of service March 9, 2022. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted medical 
records do not include valid lab requisition or medical records identifying the tests to be performed, details of 
any panels ordered, and test results. Based on this information, we decided that Medicare rules for coverage of 
code G0483 have not been met. Therefore, we decided that the Plan does not have to pay for code G0483 for 
date of service March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and laboratory services (99204, 80053, 
84134, 85025) with an oncologist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and laboratory services. You say that you have a very 
aggressive cancer. There is no professional in your area that can provide you with pain medication to control 
your pain. You would like to see the requested provider so that you can get the right treatment and allow you a 
better quality of life. The Plan denied your request. The Plan says you must receive care by network providers. 
There are multiple doctors and facilities in your area that can help with your condition. 
 
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 
an office visit and laboratory services (99204, 80053, 84134, 85025) with an oncologist to be provided by an 
out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says there is no 
documentation to support that the enrollee has tried one of the step therapy medications. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet the criteria for coverage. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred 
step one alternative. Our reviewer found that 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 45385 and 45380-59 billed for date of 
service January 25, 2023. 
 
You asked the Plan to pay for the billed 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. 
 
In this case, the CPT Code Manual definition of code 45385 is colonoscopy, flexible; with removal of tumor(s), 
polyp(s), or other lesion(s) by snare technique. The definition of code 45380-59 is colonoscopy, flexible; with 
biopsy, single or multiple.  We find that CPT codes 45385 and 45380-59 are not supported in the medical record. The records show the 
results of a colonoscopy. However, the records do not include documentation of the actual procedure 
performed on the date of service at issue. 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 
procedure codes 45385 and 45380-59 billed for date of service January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs cannot be met at a lower level of 
care. You say the enrollee will require 24-hour nursing care, daily physician monitoring and extensive physical 
and occupational therapy to return home safely. The Plan denied your request. The Plan says the IRF services 
requested 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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.