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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the criteria for IRF admission was not met and the 
enrollee's needs are currently being met at the skilled nursing 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for respiratory failure and congestive heart failure and was transferred to skilled nursing. 
Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a skin substitute. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee's infection has resolved and the 
skin substitute is being requested to avoid an extensive surgical procedure. The use of a skin substitute is 
considered the standard of care. The services are reasonable and medically necessary at this time. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a skin substitute.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 13, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that please review the attached 
supporting documentation and reprocess the claim for additional payment. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88307 billed for date of service January 
11, 2023. 
 You asked the Plan to pay for procedure code(s) 88307. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88307. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88307. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88307 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88307 billed for date of service January 11, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity solution. 
 You asked the Plan to pre-approve Evenity solution. You say that the request is medically necessary. The Plan 
denied your request. The Plan says step therapy requirements have not been met.  
 
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 Evenity solution. Our reviewer says 
that the criteria for coverage of Evenity have not been met. Our physician reviewer found the Plan requires a 
trial of Prolia or Reclast before they will approve Evenity. In this case, the enrollee has not tried and failed the 
required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity solution have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Evenity solution.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you have low blood sugar, and it has gotten so low 
at times that you have passed out before and you need the monitor to be able to view your levels. The Plan 
denied your request. The Plan says that you are not receiving insulin and you have not had any documented 
hypoglycemic episodes. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
requested CGM meets the coverage criteria. Our physician reviewer found that the enrollee was having 
symptoms highly suspicious for low blood sugars, so the enrollee meets the criteria for a CGM. Although the 
low blood sugars may be gone after stopping the dietary saturated fatty acids, the enrollee was having low 
blood sugars so the criteria for a CGM coverage was met. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
  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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this 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 the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective for the enrollee's condition. After 20 physical therapy treatments, the records do not support that the 
complexity of the enrollee's conditions are such that the skills of a professional therapist are required to achieve 
further improvement in symptoms or functional status. Further utilization of a home exercise program appears 
appropriate at this time. 
 
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 10 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot benefit from the rehabilitation at 
a lower level of care. The Plan denied your request. The Plan says the criteria for IRF admission was not met 
and the enrollee's needs can be met at a skilled nursing 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for respiratory failure and chronic obstructive pulmonary disease exacerbation. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 
billed for date of service November 16, 2022.  
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 billed for date of 
service November 16, 2022. You say that you disagree with the denial. The Plan denied your request. The Plan 
says the codes are 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 CPT code. In this case, we have confirmed that code 87150 
is a column II code to column I code 87500 and codes 87481, 87641, 87653, and 87798 are column II codes to 
column I code 87150. This claim has not been billed with an appropriate modifier to bypass the edit. The -XU 
modifier is not supported as a separate and distinct procedural service. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87150, 87481, 87641, 87653, and 87798 billed for date of service November 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve droxidopa capsules 100mg. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says droxidopa 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 droxidopa capsules 100mg.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0427-RW) provided on October 24, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that these were ET3 ambulance services, and 
the "W" modifier is appropriate in this case. The Plan denied your request. The Plan says that modifier "W" is 
an invalid destination modifier on ambulance claims. 
 
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 find that CPT code A0427-RW is supported in the medical record. Specifically, modifier W is an 
appropriate destination modifier for use with ET3 ambulance claims. Based on this information, we decided 
that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan 
has to pay for ambulance services (A0427-RW) provided on October 24, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service May 24, 
2022, to May 25, 2022. 
 
You asked the Plan to pay for procedure code S9338. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is 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 code S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service May 24, 2022, to May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81297 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 81297. The Plan denied your request. The Plan says payment for 
code 81297 is bundled into payment for code 81295. 
 
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 81297 
is a column II code to column I code 81295. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 81297 billed for date of 
service November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81294 and 81297 billed for date of service 
August 11, 2022. 
 You asked the Plan to pay for procedure codes 81294 and 81297. The Plan denied your request. The Plan says 
payment for codes 81294 and 81297 is bundled into payment for code 81292. 
 
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 81294 
is a column II code to column I code 81292. We have also confirmed that code 81297 is a column II code to 
column I code 81295. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 81294 and 81297 billed for date of service 
August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty for L3-L4. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you have been in pain for a long time. The Plan 
denied your request. The Plan says the medical criteria for a kyphoplasty have not been met. 
 
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 kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding the compression fractures being acute or 
subacute. She presented non-hospitalized with moderate to severe pain she rated at 8/10. However, detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on her daily activities. Moreover, there is MRI corroboration of plausible other causes of the lumbar pain. Therefore, the 
requested kyphoplasty at L3-4 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty for L3-L4.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary that you receive intense 
physical and occupational therapy. The Plan denied your request. The Plan says the criteria for IRF admission 
was not met and your needs can be met at a skilled nursing 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has a history of spinal cord injury and cervical spine surgery after a motor vehicle accident in 2022 and 
is living at home with ongoing weakness. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
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 IRF admission and services.