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

 
We decided that the Plan does not have to pay for the laboratory service (83789-59) provided June 13, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
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, we have confirmed that code 83789 is a column II code to column I code G0480; however, 83789 
was billed with a modifier.  
 
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 laboratory service. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. Laboratory report describes urine drug 
testing with specimen validity, in this case, urine specimen testing to ensure that it is consistent with normal 
human urine and has not been adulterated or substituted, may include, but is not limited to pH, specific gravity, 
oxidants, and creatinine. This, however, is quality assurance, not a Medicare benefit, and thus not separately 
payable by Medicare. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (83789-59) provided June 13, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an occipital nerve block (64405). 
 
You asked the Plan to pre-approve the occipital nerve block. You say that has radiating pain at the base of their 
skull. You say that this nerve block is been recommended over other therapies in patients with moderate to 
severe/debilitating occipital neuralgia symptoms as relief may last weeks or months. You also say this is 
generally the initial treatment of choice. The Plan denied your request. The Plan says that the requested service 
is not medically necessary. 
 
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 pre-approve the occipital nerve block. Our reviewer 
says that the requested occipital nerve block is considered medically reasonable and necessary in this case. Our 
physician reviewer found this treatment is the standard of care for the enrollee's condition. The documentation 
shows that the enrollee has tried and failed conservative treatments. Therefore, the reviewer found that the 
requested occipital nerve block is medically reasonable and necessary in this case. 
 
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 occipital nerve block have been met. Therefore, we decided that the Plan has 
to pre-approve an occipital nerve block (64405).  
 
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 validity testing billed with code 83789 for date(s) of service 
June 6, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 6, 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 IRF care would help in regaining functional mobility 
and strength, and would improve your quality of life. The Plan denied your request. The Plan says IRF care 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 complexity of your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You can receive further services 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary.  The Plan denied 
your request. The Plan says the criteria for SNF care has 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 require daily skilled nursing or therapy services. You do not meet the 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care.
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 
who has become deconditioned due to their hospitalization. The Plan denied your request. The Plan says the 
enrollee does 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 there are no acute rehab nursing needs documented. At the current functional level, 
the enrollee needs physical and occupational therapy services. Document does not support necessity for 
admission to an IRF. The complexity of the enrollees medical, rehab, and nursing needs does not require acute 
hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollees rehab 
needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 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 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 raised toilet seat (E0244) and handheld shower head 
(A9270) 
 
You asked the Plan to pre-approve a raised toilet seat and handheld shower head. You say that the items should 
be covered. The Plan denied your request. The Plan says these items do not primarily serve a medical purpose. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats and handheld 
shower heads are not covered because they are not primarily medical in nature.   
While a raised toilet seat and handheld shower head may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a 
raised toilet seat (E0244) and handheld shower head (A9270)
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 inpatient rehabilitation is the only chance the 
enrollee may have at returning to prior level of activity and independence and regaining quality of life. The 
Plan denied your request. The Plan says the request for inpatient rehabilitation placement does not meet 
medical necessity criteria.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do 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, at 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding commode chair (E0163) with a removable 
commode bucket (E0167). 
 
You asked the Plan to pre-approve a folding commode chair with a removable commode bucket. You say that 
the item is medically necessary. The Plan denied your request. The Plan says there is no evidence that you are 
physically incapable of utilizing regular toilet facilities for any reason and you do not use ambulatory aids in 
the home. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we 
decided that the Plan does not have to pre-approve a folding commode chair (E0163) with a removable 
commode bucket (E0167).
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 IRF admission is the correct level of 
rehabilitation. The Plan denied your request. The Plan says you do not meet the criteria for the IRF admission.  
 
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 had an uncomplicated hip fracture repair and impaired cognition. You do not 
require intensive or complex rehabilitation services. Your cognition limits your capacity to tolerate and respond 
to intensive therapy and you do 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 an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee's current wheelchair is 
over five years old and needs extensive repairs. A new wheelchair is needed instead. The enrollee has sufficient 
strength and function in upper extremities to manage standard power drives. The Plan denied your request. The 
Plan says Medicare says the upgraded electronics (expandable controller, harness and electronic connector to 2 
power options) are not covered as there is not a medical need to control the requested power options through 
the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has paraplegia. He performs self-catheterization.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that you are appealing the denial. The 
Plan denied your request. The Plan says that medical studies have not proven that this procedure is helpful for 
treatment of spondylolisthesis and the Plan does not cover it. 
 
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 bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that bone marrow aspirate is experimental when used as bone graft material. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service 
November 11, 2022. 
 
You asked the Plan to pay for procedure codes 87899 and 87900. You say that this service was necessary and 
was billed appropriately. The Plan denied your request. The Plan says this code is not supported in the records 
provided. 
 
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 procedure codes 87899 and 87900. Our reviewer says that 
these codes are not supported in the records provided. Our reviewer found the laboratory results and orders do 
not support codes 87899 and 87900. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87899 and 87900 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service November 
11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rolvedon. 
 You asked the Plan to pre-approve Rolvedon. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Rolvedon. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the documentation does not support that the enrollee has tried and failed Granix injection and Nivestym 
injection. The documentation does not support that Granix injection and Nivestym injection would likely be 
less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria 
for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rolvedon have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rolvedon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says you do not meet the weight requirements for this bed. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds but does not exceed 600 pounds.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty hospital bed have not been met. Specifically, you do not meet the weight 
requirements for this specific hospital bed. Therefore, we decided that the Plan does not have to pre-approve a 
heavy-duty hospital bed (E0303).
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 if the enrollee is not allowed access to rehabilitation, 
it will lead to poor quality of life and care. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in an inpatient rehabilitation facility.  
 
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 enrollees nursing, medical and rehabilitation needs do 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, at 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services 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.