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

 
We decided that the Plan has to pay for drug testing services (G0482) provided on December 13, 2022. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says that rules for payment have not been met. 
 
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 clear rationale for denial nor cited 
specific Medicare rules. It is the Plan's responsibility to support its denial with evidence. In this case, the Plan 
has not supported its denial, so we must find in your favor. Therefore, we decided that the Plan has to pay for 
drug testing services (G0482) provided on December 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician supervision 
(G0277, 99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy with physician supervision. You say that this is 
medically necessary. The Plan denied your request. The Plan says records do not show that the enrollee has 
been treated with debridement and resection of nonviable tissue, or that the enrollee has received and failed to 
improve with at least 30 days of standard wound care. 
 
The Plan follows Medicare rules. 
 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 hyperbaric oxygen therapy with 
physician supervision. Our reviewer says that the enrollee does not meet coverage criteria for the requested 
service. Our physician reviewer found the records do not show that the enrollee was treated with debridement 
or other standard wound care for at least 30 days to meet criteria for hyperbaric oxygen therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy with physician supervision have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician 
supervision (G0277, 99183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code E1399. 
 
You asked the Plan to pre-approve the compression stockings. You say that you were diagnosed with 
lymphedema and needs these compression stockings. The Plan denied your request. The Plan says this would 
be considered a comfort or convenience item or hygienic equipment that is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E1399 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
E1399.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the clinical documentation does not support this level of care.  
 
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 your nursing, medical, and rehabilitation needs does not 
require an acute 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, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA1, BRCA2 gene analysis; full sequence analysis and 
full duplication/deletion analysis (81162) provided on February 3, 2023. 
 
You asked the Plan to pay for BRCA1, BRCA2 gene analysis. You say that this test is a covered benefit. The 
Plan denied your request. The Plan says this testing is not covered for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that screening services such as pre-symptomatic 
genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a benefit and 
are not covered. 
 
We looked at the file and Medicare rules. The test at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Based on this information, we 
decided that Medicare rules for coverage of BRCA1, BRCA2 gene analysis have not been met. Therefore, we 
decided that the Plan does not have to pay for BRCA1, BRCA2 gene analysis; full sequence analysis and full 
duplication/deletion analysis (81162) provided on February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2023, billed on 4 
claim lines with code 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one unit of service 
of one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with one unit of service of 
a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on March 8, 2023, billed on 4 claim lines with code 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the toe nail trimming and corn/callus removal provided on 
January 13, 2023. 
 
You asked the Plan to pay for the toe nail trimming and corn/callus removal . You say that the services should 
be covered. The Plan denied your request. The Plan says these are not covered services. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the toe 
nail trimming and corn/callus removal  have not been met. Therefore, we decided that the Plan does not have to 
pay for the toe nail trimming and corn/callus removal provided on January 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45378 for date of service February 21, 2023. 
 
You asked the Plan to pay for procedure code 45378. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed with GZ modifier are automatically denied. 
 
The Plan must follow Medicare rules. Medicare rules say that claim line(s) items with a GZ modifier will be 
denied automatically. 
 
We looked at the file and Medicare rules. Procedure code 45378 was billed with modifier GZ. This means this 
code is automatically denied as billed. Based on this information, we decided that Medicare rules for coverage 
of procedure code 45378 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 45378 for date of service February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (22614, 22634, 22633), pelvic fixation 
device (22848), laminectomy (63052, 63053), and insertion of interbody biochemical device (22853). 
 
You asked the Plan to pre-approve arthrodesis, pelvic fixation device, laminectomy, and insertion of interbody 
biomechanical device. You say that this is medically necessary. The Plan denied your request. The Plan says 
records do not show that you are a non-smoker or will stop using tobacco products for at least 6 weeks before 
surgery. 
 
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 arthrodesis, pelvic fixation device, 
laminectomy, and insertion of interbody biomechanical device. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive 
conservative care measures is not evident. Additionally, you are noted to be an everyday smoker. Moreover, 
dynamic flexion/extension films are not provided in order to potentially assess the amount of movement 
(instability) at the requested surgical levels. Detailed documentation is not evident regarding potential 
impending/inevitable temporary intra-operative instability. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, pelvic fixation device, laminectomy, and insertion of interbody 
biomechanical device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
arthrodesis (22614, 22634, 22633), pelvic fixation device (22848), laminectomy (63052, 63053), and insertion 
of interbody biochemical device (22853).
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 meets the full criteria for an inpatient 
rehabilitation stay. You also say that an admission to the IRF is required as the enrollee's current needs cannot 
be safely met at a lower level of care. The Plan denied your request. The Plan says the enrollee does not meet 
all the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 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, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 home health skilled nursing visits (G0299 x6). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
reported to have vitamin B12 deficiency. The enrollee does not have a condition requiring injection and does 
not have a condition which precludes oral vitamin B12 medication. The home health visits are not medically 
necessary as the injections 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 home health skilled nursing visits (G0299 x6).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet injections (64493, 64494) 
 
You asked the Plan to pre-approve paravertebral facet injections. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria 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 paravertebral facet injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation of moderate to severe chronic low back pain. 
During recent exams, you reported a pain score of 4/10 on June 14, 2023 and July 19, 2023. The records do not 
show that you have absence of untreated radiculopathy. The review has determined that items/services at issue in this case are not medically reasonable and 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 paravertebral facet injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve paravertebral facet injections (64493, 64494)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you fell and broke your arm and hip and cannot 
walk. You say you need intensive therapy to regain function and return home safely. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (procedure code G0483) 
rendered on February 2, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in 
clinical management, exceeds the needs of the enrollee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support why drug testing for 22+ drug classes was 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive urine drug testing (procedure code G0483) rendered on February 2, 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 this type of facility offers the fastest type of recovery 
the enrollee can get. The Plan denied your request. The Plan says an IRF admission 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 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
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.