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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH level of care 
to continue receiving close monitoring by a full complement of medical staff. The Plan denied your request. 
The Plan says there are no complicated wounds or multiple complicated medications which cannot be given in 
the current location. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed tomography, thorax, low dose for lung 
cancer screening, without contrast material (71271). 
 
You asked the Plan to pre-approve a Computed tomography. The Plan denied your request. The Plan says the 
requested services are not reasonable and necessary, and the health plan has no contractual obligation to cover 
services that are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a Computed tomography. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee exceeds that age 
requirement. 
 
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 Computed tomography have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed tomography, thorax, low dose for lung cancer screening, 
without contrast material (71271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthetic leg with advanced pylon and knee 
features and other parts (L5828, L5845, L5848, L5856, L5859, L5988). 
 
You asked the Plan to pre-approve the prosthetic. You say that the prosthetic is medically necessary. The Plan 
denied your request. The Plan says the prosthetic exceeds the enrollee's needs. 
  
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 prosthetic. Our physician reviewer 
found the documentation does not support that the prosthesis with a powered and programmable 
flexion/extension assist control and a shock-reducing pylon is required. There is no clear indication that the 
enrollee has a medical condition that would require the requested components and there is no indication that the 
enrollee would require the shock-reducing pylon. 
 
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 prosthetic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the prosthetic leg with advanced pylon and knee features and other parts (L5828, L5845, 
L5848, L5856, L5859, L5988).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing,15-21 drug class(es), including 
metabolites if performed (G0482) provided November 4, 2022. 
 You asked the Plan to pay for the drug testing services. You say that say the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the documentation does 
not support that the services rendered were medically necessary. 
 
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 drug testing services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a diagnosis of chronic pain managed with 
medications including Percocet, Fentanyl, and Alprazolam. Presumptive screening results were positive for 
benzodiazepines, opiates, and oxycodone. The condition of the enrollee did not meet the Medicare rules for 
approval of definitive urine drug testing (UDT) for 15-21 drug classes (G0482). The diagnosis is medication 
management of long term (current) drug therapy. The medical record sent by the provider shows presumptive 
screening test results which are partially inconsistent with prescription medications, or history and expected 
results. It also shows the enrollee is taking a medication with abuse potential for which there was no 
presumptive test commercially available. Definitive quantitative confirmation testing was medically necessary 
for only 2 drug classes: Opiates and Fentanyls. The review has determined that the medical records provided 
did not meet the requirements listed in the LCD for Medicare coverage. 
 
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 drug testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing,15-21 drug class(es), including metabolites if performed 
(G0482) provided November 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyndamax 61MG capsules. 
 
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 the medication 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 Vyndamax 61MG capsules.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare 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 the enrollee was admitted to the acute hospital after a fall. The enrollee is able to 
perform upper body activities of daily living (ADLs) and toileting with supervision/set-up. The enrollee is able 
to transfer and walk at supervision level. The enrollee has decreased endurance. The enrollee is functioning at a 
home care level and is able to improve with repetitive exercise and support from non-skilled personnel. 
Intensive rehabilitation services and frequent physiatry oversight is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows spinal sternosis and slippage. The 
cause of the back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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 a lower level of care will place the enrollee at a 
higher risk for further decompensation. The Plan denied your request. The Plan says the enrollee's condition 
does not meet Medicare guidelines for coverage. 
 
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 fell and fractured her hand. The enrollee has chronic weakness and is at 
minimal assist for ambulation and activities of daily living. The enrollee's functional status does not require 
intensive rehabilitation or 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 10, 2022, to 
April 15, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid as billed. The Plan denied your request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code E43, defined as 
unspecified severe protein-calorie malnutrition. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the reported diagnosis is not 
supported. Our physician reviewer found the enrollee was admitted with obstructive jaundice. He is noted to 
have morbid obesity. There is no evidence that severe protein-calorie malnutrition affected his hospitalization. 
The billing of E43 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 10, 2022, to April 15, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
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 2, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of 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 
2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Plaquenil 200mg. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been stable on this medication 
for 10 years. The Plan denied your request. The Plan says the medication 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 Plaquenil 200mg.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LinQ procedure. 
 
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 the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the LinQ procedure is experimental in 
nature. More research is needed to support its use. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a LinQ procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87631) provided on December 16, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87631) 
provided on December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve test strips. 
 
You asked the Plan to pre-approve test strips. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the services requested are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for test strips. Therefore, we decided that the Plan does not have to pre-approve test strips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvis x-ray (72170) and the chest x-ray (71045) 
provided on November 6, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The diagnosis code of Z04.3 was billed as a secondary code, and it may only be reported as the primary diagnosis code. Diagnosis code Z04.3 should not be listed as secondary unless it is for a condition that is ruled 
out and is unrelated to the principal diagnosis which this was not. Based on this information, we decided that 
Medicare rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have 
to pay for the pelvis x-ray (72170) and the chest x-ray (71045) provided on November 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99233 billed for date of service August 10, 2022. 
 
You asked the Plan to pay for code 99233. You say that the medical records support payment for this code. The 
Plan denied your request. The Plan says that code 99233 billed for date of service August 10, 2022, is not 
supported in the medical record. The records do not show a detailed interval history or medical decision 
making of high complexity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which 
requires at least 2 of the 3 key components: A detailed interval history; A detailed examination; Medical 
decision making of high complexity. 
 
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 code 99233. Our reviewer says that code 99233 is supported 
by the medical record. Our reviewer found the enrollee was a then 51-year-old woman with a medical history 
that included diabetes, hypertension, epilepsy, and hyperparathyroidism, who was admitted to the hospital on 
August 9, 2022, with weakness. On August 10, 2022, the enrollee reported weakness to the point where she 
could not walk, get up, or use the bathroom. A thorough physical examination was documented. Laboratory 
studies were reviewed. An Inpatient Problem Assessment Plan is documented. Endocrinology was contacted, 
and indicated that the enrollee was safe for discharge, as her calcium should be controlled with medication if 
she takes it. Physical therapy was to be consulted. The clinical documentation supports subsequent hospital 
care, per day, for the evaluation and management of a patient, which requires at least 2 of the 3 key 
components: A detailed interval history; A detailed examination; Medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have been met. Therefore, we decided that the Plan has to pay for 
code 99233 billed for date of service August 10, 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.