Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about the enrollee's condition they do not meet all of the requirements. 
 
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 the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met 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 IRF admission and services.
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
LTACH services requested do not meet the requirements for approval.  
 
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 appears to be improving with treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 3, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on December 12, 
2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the items billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the 
unit are included in the rental allowance; there is no additional allowance for items such as electrodes, lead 
wires, and batteries. 
 
We looked at the file and Medicare rules. Review of the file shows that the items at issue are electrical 
stimulator supplies. These items are included in the rental allowance and are not separately payable.  
 
 Based on this information, we decided that Medicare rules for coverage of the electrical stimulator supplies 
have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator 
supplies provided on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetics testing rendered on September 20, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing was not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
testing was not medically necessary. Our physician reviewer found the case file does not contain sufficient 
medical documentation to demonstrate that the enrollee has a condition where clinical evaluation has 
determined the need for a medication that has a known gene-drug interaction(s) for which the test results would 
directly impact the drug management of his condition. The testing was not reasonable or medically necessary 
based on the submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the pharmacogenetics testing rendered on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
August 29, 2022, to August 31, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service August 29, 2022, to August 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the services have been met. The 
documentation submitted does not contain medical records for the date of service in question. Therefore, we 
decided that the Plan does not have to pay for the services provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service October 13, 
2022.  You asked the Plan to pay for procedure code 88341. You say that this is a payable code.  The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. The documentation does not include evidence showing that the excess units were 
provided, correctly coded, or were medically necessary. Based on this information, we decided that Medicare 
rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 88341 billed for date of service October 13, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing provided on January 18, 2023. 
 
You asked the Plan to pay for the SelectMDx testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says that this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare 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 DEX Diagnostics Exchanges shows that this testing is 
listed as covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the 
SelectMDx testing have been met. Therefore, we decided that the Plan has to pay for the SelectMDx testing 
provided on January 18, 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 CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that this device has been approved by the 
Food and Drug Administration (FDA). You also say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the requested device is considered experimental and 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 a CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case.  
Our physician reviewer found there is not enough randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, the reviewer 
found that at this time the CardioMEMS system is considered experimental and investigational and therefore 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service December 21, 
2022. 
 
You asked the Plan to pay for procedure code 99223. 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 99223 is initial hospital 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 are of high severity.  Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the medical records do not 
include the time spent counseling and coordinating care. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 for date of service December 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on December 8, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the claim is coded correctly as a critical 
care visit by pulmonary disease. You say the procedures on this date of service were by urology and other 
critical care charges are by the hospitalist group, so since these are separate specialties, they are all correctly 
coded with no additional modifiers appropriate. The Plan denied your request. The Plan says that the payment 
for this service is included in the fee for the procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a coding rule to substantiate their denial. 
Therefore, we decided that the Plan has to pay for physician's services provided on December 8, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99213) provided on December 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 
We looked at the file and Medicare rules. Payment for the requested services (99213) is included in the global 
surgery payment for the procedure (37765) provided on December 20, 2022, which has a 10-day global period. 
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 (99213) provided on December 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Avise CTD test panel provided on July 12, 2022.  
 
You asked the Plan to pay for the Avise CTD test panel. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says the clinical value and effectiveness of Avise CTD test panel in the 
setting of Systemic lupus erythematosus (SLE) has not been demonstrated in the peer-reviewed literature. 
 
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 Avise CTD test panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our physician reviewer found that the clinical value and effectiveness of Avise CTD test panel has not been 
demonstrated in the peer-reviewed literature. The Avise CTD test panel is considered experimental and 
investigational, as it is unproven to alter disease prognosis or treatment outcomes and has not been proven to be 
superior to alternative tests and measures of disease activity. The review has determined that the items/services 
at issue in this case are 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 the Avise CTD test panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the Avise CTD test panel provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this service to get care for yourself in the 
home setting as your husband is not capable to provide the care you would receive from a health care 
professional. The Plan denied your request. The Plan says the 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the facet joint injections. You say that pain medications make the enrollee 
sicker. You say that the requested injections are medically necessary for the enrollee. You also say that the 
enrollee does not want to lose their quality of life over a clerical oversight. The Plan denied your request. The 
Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients who had a consistent positive response 
of at least 80% relief of primary (index) pain. 
 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 facet joint injections. Our reviewer 
says that the requested facet joint injection is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate the enrollee had a consistent positive response of at least 80% relief 
of primary (index) pain after the first injection. Therefore, the reviewer found that the requested injection 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 the facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are requesting an expedited 
reconsideration for the denial of ten additional occupational therapy visits. The Plan denied your request. 
The Plan says the request for additional occupational therapy is not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional occupational therapy visits.