Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97014 billed for date of service August 9, 
2022, to August 18, 2022.  
 
You asked the Plan to pay for procedure code 97014. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says you have billed a code on this outpatient 
hospital claim that has a MUE value of 0.  That code (97014) is not payable, so the claim cannot be 
adjudicated. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid.  
 In this case, the MUE for CPT code 97014 is 0. This means that this code is not a payable code. Based on this 
information, we decided that Medicare rules for coverage of procedure code 97014 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 97014 billed for date of service 
August 9, 2022, to August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member is not mobile and is not able to do any 
daily activities on their own. The member been in the hospital for 40 days already. The Plan denied your 
request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility (IRF) services you are 
requesting 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for meningitis. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. While the medical records support a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the medical necessity for 
IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information 
we have about the enrollee's condition they don't meet all of the requirements. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for an above the knee amputation. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81001 billed on January 19, 2023. 
 
You asked the Plan to pay for 81001. You say that this was billed correctly. The Plan denied your request. The 
Plan says this 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 81001 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, with microscopy. 
 
We find that CPT code 81001 is not supported in the medical record. Specifically, the record indicates that 
urinalysis without microscopy was performed. Based on this information, we decided that Medicare rules for coverage of 81001 have not been met. Therefore, we decided that the Plan does not have to pay for code 81001 
billed on January 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member is need of the rehabilitation in order to 
regain maximum function and they have submitted medical documentation to support the admission. The Plan 
denied your request. The Plan says based on Medicare guidelines, 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for congestive heart failure and acute kidney injury.  Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lipid panel (80061) and glycosylated hemoglobin test 
(83036) provided on July 22, 2022. 
 
You asked the Plan to pay for the lipid panel and glycosylated hemoglobin test. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lipid panel and glycosylated 
hemoglobin test have been met. Specifically, records were requested and never received. Therefore, we decided 
that the Plan does not have to pay for a lipid panel (80061) and glycosylated hemoglobin test (83036) provided 
on July 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on December 29,  2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage provided on December 29,  2022. You say that the patient was deconditioned, bed confined, and 
cannot be transported safely by any other means. The Plan denied your request. The Plan says the records show 
the enrollee is able to transfer with assistance and is not bed-bound. The member does not have any acute 
conditions which require continuous monitoring. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance service, basic life support, 
non-emergency transport and ground mileage provided on December 29,  2022.  Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
transportation via ambulance from the hospital  was not medically necessary. The enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport.  Transportation could have been provided by other means (stretcher van, wheelchair van, private car, 
taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport and ground 
mileage provided on December 29,  2022. have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance service, basic life support, non-emergency transport and ground mileage provided 
on December 29,  2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an anterior cervical spine fusion at levels C7-T1 
(22551) and the insertion of a biomechanical device (22853). 
 
You asked the Plan to pre-approve a spinal fusion and biomechanical device. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 a spinal fusion and biomechanical 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the detailed documentation regarding a trial and 
failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. Additionally, the provided examinations did not corroborate any objective findings of radiculopathy of the 
cervical spine. Moreover, the provided cervical magnetic resonance imaging from March 7,2023, did not 
demonstrate significant pathology at the requested surgical level. 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. Therefore, the requested anterior cervical fusion with a biomechanical device, in this case, is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal fusion and biomechanical device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an anterior cervical spine fusion at levels C7-T1 (22551) 
and the insertion of a biomechanical device (22853).
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 exceeds the established 
defining criteria for an appropriate Long Term Acute Care Hospital admission. The Plan denied your request. 
The Plan says admission to the LTACH does not meet medical necessity. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care is not safe, sufficient or 
equipped to address the enrollee's needs related to his comorbidities and allow him the opportunity to gain a 
higher level of functioning to improve his quality of life. The Plan denied your request. The Plan says the 
member does not meet the Medicare criteria for admission to an inpatient rehabilitation facility (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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a urinary tract infection. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
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 use of bone marrow aspirate is 
considered experimental in spine surgery. 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 bone marrow aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 Mis Receiver. 
 
You asked the Plan to pre-approve the CGM. You say that the item is medically necessary. The Plan denied 
your request. The Plan says a continuous glucose monitor is not covered under Medicare if the enrollee does 
not have documentation of history of problematic hypoglycemia. 
 
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. Our physician reviewer 
found the record indicates that the enrollee has diabetes. The record provided does not indicate that the enrollee 
is being treated with insulin or has problematic hypoglycemia as defined by the Medicare rules. The elements 
of the coverage criteria are not 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 the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Dexcom G6 Mis Receiver.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Mis Sensor. 
 
You asked the Plan to pre-approve a Dexcom G7 Mis Sensor. You say that a Dexcom G7 Mis Sensor is 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria. 
 
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 a Dexcom G7 Mis Sensor. Our 
reviewer says that the service/item is not medically necessary. Our physician reviewer found the enrollee has 
neither low blood sugars documented (nor is on a medicine that typically causes low blood sugars) and is not 
on insulin. Although a CGM may help the enrollee with blood sugar control, criteria for CGM coverage are not 
met 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 a Dexcom G7 Mis Sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G7 Mis Sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 28, 2022, to December 
29, 2022. 
 
You asked the Plan to pay for the services. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable 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 the services are not supported in the medical record. Specifically, Modifiers GN, GO, and GP 
refer only to services provided under plans of care for physical therapy, occupational therapy and speech-
language pathology services. They should never be used with codes that are not on the list of applicable therapy 
services. For example, respiratory therapy services, or nutrition therapy services shall not be represented by 
therapy codes which require GN, GO, and GP modifiers. Revenue code 42x (physical therapy) lines may only 
contain modifier GP. The claim is not payable as billed. 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 provided on December 28, 2022, to December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis receiver.  
You asked the Plan to pre-approve the Dexcom G6 Mis receiver. The Plan denied your request. The Plan says a 
CGM is not covered under Medicare if the member does not have documentation of history of problematic 
hypoglycemia. 
 
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 Dexcom G6 Mis receiver. Our 
reviewer says that the Dexcom G6 Mis receiver is not a medically necessity. Our physician reviewer found 
based on the medical records provided there is no documentation that the Dexcom G6 continuous glucose 
monitor at issue in this case meets all Medicare for medically reasonable and necessary for the patient. 
Provided records in this case document the enrollee's sugar fluctuate but the records do not document the 
patient is insulin-treated or has a history of problematic hypoglycemia. 
 
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 Dexcom G6 Mis receiver have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 Mis receiver.