Persius/hicric huggingface dataset:
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 services will help the enrollee make measurable 
gains and improve medical status to ensure a safe discharge home. The Plan denied your request. The Plan says 
ongoing skilled care can be provided in an alternative setting. 
 
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 is medically stable. While the enrollee may benefit from physical and 
occupational therapy, their rehab needs can be provided in a lower intensity and alternate setting such 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 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 the SelectMDx testing rendered on January 10, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that that only the Progensa PCA3 and ConfirmMDx tests 
have met Medicare coverage criteria. 
 
We looked at the file and Medicare rules. The testing at issue is SelectMDx. This test is not covered by the 
Medicare criteria. 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 pay for the SelectMDx testing 
rendered on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99212) provided on September 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99212) is included in the global 
surgery payment for the procedure (64635) provided on September 6, 2022, which has a 10-day global period. 
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 the services (99212) provided on September 14, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot provided to you on November 16, 2022. 
 
You asked the Plan to pay for the walking boot. The Plan denied your request. The Plan says this is not covered 
for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the walking boot provided to you on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0127 billed for August 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that code G1027 was not billed with a required 
anatomical modifier. 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 pay for procedure code G0127 billed 
for August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with code G0482 for October 24, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0482 is not supported. 
 
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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the file shows that only nine 
drug classes were tested, not 15-21. 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 pay for the drug testing 
billed with code G0482 for October 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tildrakizumab. 
 You asked the Plan to pre-approve Tildrakizumab. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Tildrakizumab. Our reviewer says that 
the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a history of plaque psoriasis and joint pain. The documentation does not support that the 
enrollee has tried and failed phototherapy and Enbrel or Humira THe documentation does not support that 
phototherapy and Enbrel or Humira would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tildrakizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tildrakizumab.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88237 and 88264 provided on June 1, 2022. 
 
You asked the Plan to pay for procedure codes 88237 and 88264. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says this claim was 
not submitted with a diagnosis which supports the medical necessity of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of codes 88237 and 88264. Any codes which are not listed are considered not medically 
necessary for codes 88237 and 88264. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with diagnosis codes 
which are not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for procedure codes 88237 and 88264 provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraocular eye injections for macular degeneration with 
an out of service area (OOSA) provider.  
You asked the Plan to pre-approve intraocular eye injections for macular degeneration. You say that you have 
been receiving an injection once every 5 weeks with an in-network provider. The injection is to treat your 
retina and to work on clearing up your vision. You need the Plan to cover your next injection in July with an 
OOSA provider because you will be on vacation in a different state, and it is too expensive for you to pay out 
of pocket. The Plan denied your request. The Plan says you must use network providers to get your medical 
care and services. There are in-network providers available. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 
Based on this information, we decided that Medicare rules for coverage of intraocular eye injections for 
macular degeneration have not been met. Therefore, we decided that the Plan does not have to pre-approve 
intraocular eye injections for macular degeneration with an out of service area (OOSA) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee needs a six-month follow-up. The 
Plan denied your request. The Plan says network providers are available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve an 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 7, 2022, billed 
with codes 81270, 81279, 81219, 81338, and G0452. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using 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 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 
November 7, 2022, billed with codes 81270, 81279, 81219, 81338, and G0452.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio device provided on December 22, 2022. 
 
You asked the Plan to pay for the Cala Trio device. You say that the enrollee's plan paid for the enrollee's 
initial Cala Trio wristband. You say that the enrollee is having improvement and control with their hand 
tremor. You also say that the use of the device allows the enrollee to avoid any type of invasive and costly 
surgical procedures. The Plan denied your request. The Plan says the device in this case is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that use of electric nerve stimulation in the treatment of 
motor function disorders, such as multiple sclerosis, is a recent innovation, and the medical effectiveness of such therapy has not been verified by scientifically controlled studies. 
 
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 Cala Trio device. Our reviewer says that 
the Cala Trio device was not medically necessary. Our physician reviewer found the Cala Trio device is not 
considered reasonable and necessary to treat motor function disorders as the medical effectiveness of such 
therapy has not been verified by scientifically controlled studies. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan 
does not have to pay for the Cala Trio device provided on December 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nuclear medicine liver imaging. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested test is not the appropriate test for the enrollee's condition. 
 
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 requested services. Our physician 
reviewer found that the enrollee had a computed tomography (CT) urogram revealed a subcapsular area of 
enhancement segment 2 of the liver.  A magnetic resonance imaging (MRI) of the abdomen without and with 
contrast, was recommended and would be appropriate. The requested nuclear medicine study is not appropriate 
for evaluation in this case. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nuclear medicine liver imaging.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 23, 2022, to 
April 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you do not agree that the dates 
on the NOA and the claim have to match. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 23, 2022, to April 
21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular PNS device (64555, L8679). 
 
You asked the Plan to pre-approve a stimulator device. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the clinical value and effectiveness of an auricular PNS device in the setting 
of chronic pain syndrome have not been demonstrated in the peer-reviewed literature. Medical studies have not 
proven this service/item is helpful for the treatment of your health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a stimulator device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the auricular peripheral nerve stimulation is proposed to manage your back and lower 
extremity pain. Auricular peripheral nerve stimulation adds electrical stimulation to acupuncture. There is very 
little support in the medical literature for this methodology. The only randomized controlled trial evaluating the 
methodology for back pain in the national library medicine is from 2003 and concluded additional research is 
needed before recommendations may be made about the procedure. Per SSA 1862 (a)1 (A) criteria is not met 
as the proposed methodology is not the standard of care and has not been shown to be as effective as the 
standard 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 a stimulator device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an auricular PNS device (64555, L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99406) provided on October 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 99406 is "Smoking and tobacco use cessation counseling 
visit; intermediate, greater than 3 minutes up to 10 minutes". 
 
We find that CPT code 99406 is not supported in the medical record. Specifically, the records provided do not 
include the time spent providing the counseling services. 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 the services (99406) provided on October 18, 2022.
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 you need this additional help. The Plan denied your 
request. The Plan says these services have been correctly denied. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 the services (99204) provided on December 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter". 
 
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 the services. Our reviewer says that the use of code 99204 is not supported by the records provided. Our reviewer found that provided records do not document a chief 
complaint, an extended history of present illness, a review of all additional body systems and a complete past, 
family and social history. The records do not document 45-59 minutes of total time was spent on the date of the 
encounter. 
 
We looked at this coder'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 the services (99204) provided on December 28, 2022.