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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are 
medically necessary. The Plan denied your request. The Plan says criteria for admission to an LTACH has not 
been met.  
 
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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a lung transplant patient, and you 
would like the enrollee to be placed in an IRF so they can get the treatment that is needed such as medications 
being administered at the same time daily. You also say that a skilled nursing facility will increase the enrollee 
being exposed to infections. The Plan denied your request. The Plan says based on the available information, 
admission to an IRF is not reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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. Our reviewer also found that the enrollees 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for etelcalcetide (J0606-AX) provided from February 1, 2023, to 
February 27, 2023. 
 
You asked the Plan to pay for etelcalcetide. You say that the Plan is required to pay for this. The Plan denied 
your request. The Plan says this was not coded correctly per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that code J0606 should not be processed when billed 
with modifier -AX on Type of Bill 72X.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of etelcalcetide have not been met. Therefore, we decided that the Plan does not have to pay for 
etelcalcetide (J0606-AX) provided from February 1, 2023, to February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and wound care services provided on May 9, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit and wound care services. You say that this was medically 
necessary. The Plan denied your request. The Plan says this was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and wound care services provided 
on May 9, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43239 billed for date of service January 25, 
2023. 
 You asked the Plan to pay for procedure code 43239. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code 43239 is bundled into payment for code 
43251. 
 
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 43239 
is a column II code to column I code 43251. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 43239 billed for date of service January 25, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service June 10, 
2022.  
 
You asked the Plan to pay for procedure code 87798. You say that these services were necessary and are 
supported in the medical record. 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 87798 is 13. The MAI value for this code is 3. You billed 21 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytogenetics testing identified with codes 88271 and 
88275 for date of service February 6, 2023. 
 
You asked the Plan to pay for the cytogenetics testing identified with codes 88271 and 88275. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered were not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cytogenetics testing is only covered for certain 
indications.  
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 cytogenetics testing identified with codes 
88271 and 88275. Our reviewer says that the documentation does not support that the services rendered were 
medically reasonable or necessary. Our physician reviewer found the enrollee a history of PEs (on Eliquis) and 
prostate cancer status post external beam radiation therapy (EBRT) 2013 with current prostate-specific antigen 
(PSA) of 0. The enrollee developed a new bladder tumor and underwent a trans urethral resection of bladder 
tumor (TURBT) on September 13, 2022, with reported high grade urothelial carcinoma T1 as well as 
recurrence. Due to intolerance to intravesical therapy, the enrollee was recommended for upfront cystectomy. 
The enrollee is now status post open radical cystoprostatectomy (in the setting of previous pelvic radiotherapy), 
extended pelvic lymph node dissection, ileal conduit diversion on January 4, 2023. The enrollee was 
discharged on patient-oriented discharge 5 in stable condition with home health care. The enrollee's Jackson-
Pratt (JP) drain and red rubber catheter were removed prior to discharge. The enrollee did not meet one of the 
diagnosis criteria of the NCD above.  
 
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 cytogenetics testing identified with codes 88271 and 88275 have not been 
met. Therefore, we decided that the Plan does not have to pay for the cytogenetics testing identified with codes 
88271 and 88275 for date of service February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous laser ablation (EVLA). 
 
You asked the Plan to pre-approve the EVLA. You say that the enrollee reports swelling in the summer heat, 
including pain, and restless leg syndrome that the enrollee did not associate with venous insufficiency. You say that the imaging shows significant reflux. You also say that the enrollee met all criteria including a positive an 
ultrasound and should be approved. The Plan denied your request. The Plan says there is no indication of 
significant pain or edema that interferes with the enrollee's activities of daily living (ADLs). 
 
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 the EVLA. Our reviewer says that the 
requested EVLA is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee is not experiencing any pain or lifestyle or mobility limiting symptoms. The 
documentation mentions leg fatigue that is equal in the lower extremities bilaterally however other than one 
focal area at the calf, there is essentially no significant superficial venous reflux on the right. This would 
suggest an alternative etiology for the patients bilateral leg fatigue. Therefore, the reviewer found that the 
requested EVLA 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 the EVLA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve endovenous laser ablation (EVLA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 66984 billed for date of service November 
29, 2022.  
 You asked the Plan to pay for procedure code 66984. You say that you disagree with the denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 66984 is 1. The MAI value for this code is 2. You billed 11 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 66984 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 66984 billed for date of service November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Mis 2 continuous glucose monitor 
(CGM) reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM reader. You say that the enrollee will benefit 
greatly from the requested CGM reader. The Plan denied your request. The Plan says a CGM is not covered 
under Medicare if the enrollee is not on insulin or does not have documentation of recurrent problematic 
hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 CGM reader have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre Mis 2 continuous glucose monitor (CGM) reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on October 27, 2022. 
 
You asked the Plan to pay for initial hospital care (99223). The Plan denied your request. The Plan says the 
medical records submitted do not support procedure code 99223. 
  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 initial hospital care (99223) have been 
met. Specifically, medical records for the date of service at issue were not submitted. Therefore, we decided 
that the Plan does not have to pay for initial hospital care (99223) provided on October 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has tried other alternatives without 
success, and trying viscosupplementation was discussed, and the enrollee wishes to proceed. You also say that 
it is medically necessary to provide treatment to alleviate the pain and Medicare pays for viscosupplementation 
in the shoulder. The Plan denied your request. The Plan says Euflexxa is only indicated for Osteoarthritis of the 
Knee. The Plan also says that they are therefore unable to approve Euflexxa for the enrollee's shoulder. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Euflexxa is not FDA-approved for the enrollee's diagnosis. Our reviewer also found that its 
use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services (CMS) approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says based on the clinical information received, 
the enrollee does not meet the guidelines for LTACH services.  
 
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 that there is no documentation provided indicating the medical necessity for 
admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees 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 seizures and unilateral 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit and does not have to pay for 
the self-administered drugs provided from March 21, 2023, to March 23, 2023. 
 
You asked the Plan to waive the copayment for . You say that you did not have a knee replacement. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. The Plan also says the medication is 
not covered as a medical benefit under the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for an emergency room visit.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B generally does not pay for drugs 
that are usually self-administered by the patients who take them. 
 
You have been asked to pay a $100 copayment for the ER visit. This item/service falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
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 waive the copayment for the ER visit and does not have to 
pay for the self-administered drugs provided from March 21, 2023, to March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 87798 billed for date of service January 11, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that you disagree with the denial. 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 87798 is 13. The MAI value for this code is 3. You billed 16 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service January 11, 2023.