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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the established 
criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 that the enrollee appears to be somewhat unstable but responding to treatment and 
should only require short-term additional acute care services that can safely be provided at the current facility  
 until more stable and appropriate for transfer to a lower level of care. The enrollee does not require services at 
the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801, 87798, and 87150 billed for 
December 30, 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 codes 87801, 87798, and 87150 are 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. 
 
87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) 
technique. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. The definition of code 87150 is culture, typing; 
identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each 
organism probed. 
 
We find that CPT codes 87801, 87798, and 87150 are not supported in the medical record. Specifically, there 
are no results of infectious agent detection by nucleic acid for multiple organisms to support code 87801. There 
are no results of infectious agent detection by nucleic acid, not otherwise specified, to support code 87798. 
There are no results of infectious agent detection by nucleic acid amplified probe technique, per culture or 
isolate, each organism probed, to support code 87150. 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 codes 87801, 87798, and 87150 billed for December 30, 2022.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about the enrollee's condition the requirements have not been met, care can be provided in the current 
inpatient hospital. 
 
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 enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from June 30, 2022, to 
July 29, 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 30, 2022. The NOA was not received by the Plan until May 9, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
June 30, 2022, to July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services, supplies, and injections billed with 
codes A4657, 82040, 82310, 82374, 82435, 82565, 82728, 83540, 84075, 84100, 84132, 84155, 84295, 84450, 
84460, 86706, 87340, J0882, J1270 for February 1, 2023, by a non-network provider.  
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 services were rendered by a non-network provider without prior authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services, supplies, and injections 
billed with codes A4657, 82040, 82310, 82374, 82435, 82565, 82728, 83540, 84075, 84100, 84132, 84155, 
84295, 84450, 84460, 86706, 87340, J0882, J1270 for February 1, 2023, by a non-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis omega3, per square centimeter (Q4158). 
 
You asked the Plan to pre-approve skin substitute. You say that the enrollee has a biopsy proven basal cell 
carcinoma located on the right distal pretibial region. Due to the wound size and location, the skin substitute is 
being requested to assist and promote proper wound healing post Mohs procedure. The Plan denied your 
request. The Plan says the request is not medically necessary because the records show the enrollee does not 
show that this skin substitute, will be used to treat a chronic wound that has failed comprehensive wound 
therapy over a period of at least 30 days. 
 
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 skin substitute. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Kerecis Omega3 skin substitute in MMS reconstruction is not considered the standard of 
care and is not medically necessary. More medical research is needed to support this is safe and effective for 
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 skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Kerecis omega3, per square centimeter (Q4158).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option (K0861), an electronic connection (E2311), a harness (E2313), an expandable controller (E2377), 
and additional related items and accessories (E1007, E1012, E2361, E2603, and K0108).  
 
You asked the Plan to pre-approve the group 3 standard power wheelchair with multiple power options and 
related accessories. You say that it is medically necessary for the enrollee to receive a complex power 
wheelchair. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power options available with a K0861 group 3 power wheelchair. The Plan also says that the related 
accessories are not medically needed. 
 
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 group 3 standard power wheelchair 
with multiple power options and related accessories. Our reviewer says that the requested items are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a 
neurologic disorder with functional deficits.  The documentation does not indicate that the enrollee requires 
intermittent catheterization of the bladder or have spasticity that would necessitate power recline.  Although the 
enrollees condition may meet criteria for a power wheelchair (PWC), the criteria for this specifically requested 
PWC with multiple power options including power tilt and recline are not met. 
 
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 group 3 standard power wheelchair with multiple power options and related 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
standard power wheelchair with multiple power option (K0861), an electronic connection (E2311), a harness 
(E2313), an expandable controller (E2377), and additional related items and accessories (E1007, E1012, 
E2361, E2603, and K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rybrevant. 
 
You asked the Plan to pre-approve Rybrevant. You say that the enrollee has a rare diagnosis with poor 
outcomes. The Plan denied your request. The Plan says Rybrevant is not medically necessary.  
 
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 Rybrevant. Our reviewer says that 
Rybrevant is not medically necessary. Our physician reviewer found that the requested use of Rybrevant is not 
FDA-approved. Rybrevant is also not supported by one of the drug compendia or by clinical research. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rybrevant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rybrevant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions with sedation (dental codes D7140, D7210, 
D9239, and D9243). 
 
You asked the Plan to pre-approve dental services. You say that you cannot afford these services. The Plan 
denied your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
extractions with sedation (dental codes D7140, D7210, D9239, and D9243).
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 is in need of rehabilitation after having 
lung surgery. You say the enrollee has multiple issues and feel they would benefit from rehabilitation. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided March 
27, 2023.  

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. The definition of code 80307 is drug test(s), 
presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry 
analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, 
GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-
MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of 
service. 
 
Codes G0483 and 80307 remain not supported. The medical records submitted do not include an order that 
specifically list what test(s) are to be performed in the custom panel. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (80307 and G0483) provided March 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) home health physical therapy visits (G0151 x5).  

You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five (5) home health physical therapy visits (G0151 x5).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the best option for the enrollee to make a 
full recovery is to go to an LTACH. The Plan denied your request. The Plan says that an LTACH admission is 
not medically necessary.  
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee requires LTACH services as they do not meet admission criteria for a skilled 
nursing facility due to their current respiratory status. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Confirm MDx testing (81551) provided on March 21, 
2023. 
 
You asked the Plan to pay for the testing. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says the enrollee was not being considered for a repeat biopsy due to persistent risk 
factors such as elevated/rising PSA and/or abnormal digital rectal exam (DRE) by repeat testing.  
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 testing. Our physician reviewer found 
Confirm MDx was performed prematurely and did not meet the second criteria as listed as the enrollee was not 
being considered for a repeat biopsy or had documentation of abnormal DRE. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Confirm MDx testing (81551) provided on March 21, 2023.