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

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that the requested Synvisc-One is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for Synvisc-One. 
 
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 Synvisc-One. Our reviewer says that 
the enrollee does not meet criteria for Synvisc-One. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The documentation submitted, more than one year old, is insufficient to 
determine that the elements of the coverage criteria are currently satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that you require skilled nursing services with the 
specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide care 
only in a SNF. You do not have complex wound care, or other skilled nursing needs that require a SNF 
admission. Your functional level does not require the skills of a professional therapist only in a SNF. You do 
not require skilled nursing or skilled therapy on a daily basis. As a practical matter, your needs do not require 
the necessary services on an inpatient basis in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43262 rendered on May 10, 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 CPT 43262 is considered inclusive to CPT 43274, and the records do not support CPT 43262 as 
distinct or independent from other services performed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that CPT 
43262 is not supported as a separate and distinct procedure. The components of 43262 are included in 43274. 
The record does not support that a separate and distinct procedure was performed; it is included in 43274. 
 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 procedure code 43262 rendered on May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 CGM.  
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have not been met. 
 
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 have diabetes, 
use insulin or have a history of problematic hypoglycemia Based on this information, we decided that Medicare 
rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 3 CGM.
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's treating physician states the IRF care is 
medically necessary. The Plan denied your request. The Plan says the IRF care is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such as 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation does not 
support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain the 
enrollee's functional status.  The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the seat lift mechanism, electric, any type (E0627) 
purchased March 6, 2023. 
 
You asked the Plan to reimburse you for the seat lift mechanism. You say that please reconsider and reimburse 
you for the amount paid. The Plan denied your request. The Plan says this item was purchased from a supplier 
that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the seat lift mechanism, 
electric, any type (E0627) purchased March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve E2300. We decided that the Plan does not have to pre-approve 
E2301.  
 
You asked the Plan to pre-approve a power seat elevator (E2300) and a power standing system (E2301).. You 
say that this is medically necessary. The Plan says that this is not covered because it is not primarily medical in 
nature. 
 
We decided that the Plan has to pre-approve E2300.  
 
The Plan follows Medicare rules. Medicare rules say that durable medical equipment is covered when 
medically appropriate for the enrollee's condition. 
 
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 for E2300. Our reviewer says that the enrollee is 
dependent for transfers and a power seat elevator is indicated for assistance of performing transfers and daily 
activities. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve E2300.  
 
We also decided that the Plan does not have to pre-approve E2301. 
 
The Plan follows Medicare rules. Medicare rules say that durable medical equipment is covered when 
medically appropriate for the enrollee's condition. 
 
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 for E2301. Our reviewer says that a power standing 
system has not been supported by the medical literature to significantly improve independence or physiological 
outcomes. A standard standing frame can be utilized if needed for lower extremity contracture and spasticity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of E2301 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve E2301. 
 
 
 
 
 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 covered when not incident to physician's services. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.  
 
Benefits for these services 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee has made progress and is ready to go 
into a skilled nursing facility to get back to their baseline. The Plan denied your request. The Plan says the 
enrollee can stay in the hospital until they are safe for transfer or discharge. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
clinical documentation does not show that the enrollee is medically stable for daily skilled services in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94726, 94060, and 94729, billed for date of 
service April 3, 2023. 
 
You asked the Plan to pay for procedure codes 94726, 94060, and 94729. The Plan denied your request. The 
Plan says these codes are 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 this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 94726 and 94060. 
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) 94726 and 
94060. Based on this information, we decided that Medicare rules for coverage of procedure code 94726 and 
94060 have not been met. 
 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 94729 
is an add-on code and has not been billed with an appropriate payable primary procedure code. 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 94726, 94060, and 94729, billed for date of service April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM), supplies 
and receiver. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that by using the Dexcom CGM you were 
able to lose 70 pounds over the past 2 years and you have lowered you A1C from 7.7 to 5.3 while at the same 
time eliminating the need for both long acting and short acting insulin. The Plan denied your request. The Plan 
says it was determined that you do not have a history of low blood sugar or use insulin. 
 
The Plan follows 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 and supplies. Our reviewer 
says that these items are not medically necessary. Our physician reviewer found coverage criteria for CGM 
require insulin use or low blood glucose sugar. You are not on insulin, are not having low blood glucose sugar, 
nor on medications that typically cause low blood glucose sugar. Although the CGM has helped you lose 
weight and improve your control, you likely have learned from use of the CGM which foods you can eat and 
tolerate and which you cannot. Although the CGM has helped you, you do not meet criteria coverage 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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom continuous glucose monitor (CGM), supplies and receiver.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87653, 87798, 87801) provided on May 
10, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 87481, 87653, 87798, & 87801 are not supported in the medical record. Specifically, 
multiple unbundled codes were billed for a single panel. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (87481, 87653, 87798, 87801) provided on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87507, 87324) provided on June 9, 2023. 
 You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
In this case, the CPT Code Manual definition of code 87507, & 87324 isInfectious agent detection by nucleic 
acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, 
norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe 
technique, multiple types or subtypes, 12-25 targets.  
 
We find that CPT code 87507 is not supported in the medical record. Specifically, the records show testing for 
more than 25 targets. A bundled relationship exists between codes 87324 and 87507. Code 87324 was not 
billed with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(87507, 87324) provided on June 9, 2023.
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 services are necessary for you to 
continue receiving the care needed. The Plan denied your request. The Plan says you can receive the care 
needed in the hospital or in another setting. 
 
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 the record indicates that you have ongoing acute medical issues and still require acute 
care services. The medical record does not indicate that you require services that you are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be recommended. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panitumumab, atropine sulfate, dexamethasone and 
irinotecan. 
 
You asked the Plan to pre-approve panitumumab, atropine sulfate, dexamethasone and irinotecan. You say that 
the requested drugs are medically necessary for the enrollee. The Plan denied your request. The Plan says the 
drug regimen is not being prescribed for a supported medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 panitumumab, atropine sulfate, 
dexamethasone and irinotecan. Our reviewer says that the service is not medically necessary. Our physician 
reviewer says that the requested use of panitumumab, atropine sulfate, dexamethasone and irinotecan is 
not Food and Drug Administration-approved for the enrollee's diagnosis and is not supported by one of the 
major drug compendia or by a CMS-approved medical journal. The use of panitumumab, atropine sulfate, 
dexamethasone and irinotecan in this case does not meet Medicare criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panitumumab, atropine sulfate, dexamethasone and irinotecan have not been 
met. Therefore, we decided that the Plan does not have to pre-approve panitumumab, atropine sulfate, 
dexamethasone and irinotecan.