Persius/hicric huggingface dataset:
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 an IRF admission is not medically necessary. The 
Plan denied your request. The Plan says the enrollee requires continued medical management of their 
comorbidities and polypharmacy needs as well as daily physical therapy and occupational therapy to address 
current deficits.  
 
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 that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) (G0277x320) and 
physician or other qualified health care professional attendance and supervision of HBOT (99183x80). You asked the Plan to pre-approve HBOT. You say that you are requesting reconsideration due to severe 
vascular dementia, with other behavioral disturbance. The Plan denied your request. The Plan says the enrollee 
does not have any of the above indicated diagnosis, the coverage of the procedure cannot be granted. 
 
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 HBOT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has vascular dementia and HBOT is not indicated per literature for standard of care 
therapy. HBOT is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy (HBOT) (G0277x320) and physician or other qualified health care 
professional attendance and supervision of HBOT (99183x80).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical genetics and genetic counseling services, each 
30 minutes face-to-face with patient/family (96040) provided on April 11, 2023. 
 
You asked the Plan to pay for the services. You say that there was no other service on this date. The Plan 
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network 
provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
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 medical genetics and genetic counseling 
services, each 30 minutes face-to-face with patient/family (96040) provided on April 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion, drug-delivery implant (ie, bioresorbable, 
biodegradable, non-biodegradable) rendered on December 6, 2022. 
 
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 the records do not support the services 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 11981 is "Insertion, drug-delivery implant (ie, 
bioresorbable, biodegradable, non-biodegradable)." 
 
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 services at issue in this case were not supported by the medical records. Our reviewer found that the medical record includes a 
operative report for total knee arthroplasty, which does not include documentation of drug-delivery implant 
insertion. 
 
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 insertion, drug-delivery implant (ie, bioresorbable, biodegradable, non-biodegradable) rendered 
on December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) with a pain management 
specialist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like an OON exception because the 
in-network providers are not listening to you. The Plan denied your request. The Plan says you must use 
network providers for your health care services. There are in-network providers within a reasonable distance 
from your location that can provide this service. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99203) with a pain management specialist to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extracranial arteries (93880-TC) and the 
office visit (99214) provided on January 25, 2023. 
 
You asked the Plan to pay for the services. You say that you submitted the medical records for review. 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 93880 is duplex scan of extracranial arteries; complete 
bilateral study. The definition of code 99214 is office or other outpatient visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 30-39 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 found the documentation doe not 
support procedure code 93880. The duplex reported was completed and interpreted by a different provider. The 
documentation does not support procedure code 99214. The documentation does not state the time spent. There 
is insufficient for medical decision making (MDM) to warrant 99214. 
 
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 duplex scan of extracranial arteries (93880-TC) and the office visit (99214) provided on 
January 25, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Foundation One liquid biopsy testing (0239U) provided on April 6, 
2023. 
 You asked the Plan to pay for the testing. You say that the Medicare requirements for coverage were met.  The 
Plan denied your request. The Plan says that the records do not show that the enrollee's cancer was not 
advanced, metastatic, or returned.  
 
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 
there is documentation that support that the Foundation One liquid biopsy testing (0239U) provided on April 6, 
2023, at issue in this case meets all Medicare criteria for medically reasonable and necessary for the patient. 
Provided records in this case document the patient has metastatic breast cancer; and a clinical indication for 
germline (inherited) testing for hereditary breast or ovarian cancer; and a risk factor for germline (inherited) 
breast or ovarian cancer; and has not been previously tested with the same germline test using NGS for the 
same germline genetic content and the diagnostic laboratory test using NGS has all of the following: FDA-
approval or clearance; and results provided to the treating physician for management of the patient using a 
report template to specify treatment options. 
 
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 been met. Therefore, we decided that the Plan has to pay for the 
Foundation One liquid biopsy testing (0239U) provided on April 6, 2023.  
 
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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says based on the available information, admission to IRF is not 
reasonable and necessary, as the enrollee's condition does not meet the Medicare 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 drug testing, 15-21 drug class(es) (G0482) provided on 
October 25, 2022. 
 
You asked the Plan to pay for the drug testing. 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 G0482 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; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, review of the the submitted 
medical records indicate this procedure was collected/performed on October 26, 2022, not October 25, 2022. 
We have insufficient documentation to corroborate the services; therefore, we cannot confirm Medicare 
coverage has been met. Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing, 15-21 
drug class(es) (G0482) provided on October 25, 2022.
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 needs long-term acute care 
hospitalization upon discharge from their current level. The Plan denied your request. The Plan says 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 not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided 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 LTACH services.
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. The Plan denied your request. The Plan says the enrollee has no 
medical conditions which would require the thrice weekly physician visit. Services needed may be provided 
safely in a lower level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services (99495) provided on 
January 2, 2023. 
 You asked the Plan to pay for the service. You say that the procedure billed is substantiated in the attached 
medical record. The Plan denied your request. The Plan says the provider did not bill as required by Medicare 
coding regulations. 
 
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 99495 is transitional care management services with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during 
the service period Face-to-face visit, within 14 calendar days of discharge. 
 
Review of the file shows the claim processed correctly due to discharge claim never filed. We are unable to 
accurately determine if transitional care is within the 30-day period. Determination based on Centers for 
Medicare & Medicaid Services (CMS) Document MLN908628 - Transitional Care Management Services 
(cms.gov). Based on this information, we decided that Medicare rules for coverage of the service have not been 
met. Therefore, we decided that the Plan does not have to pay for transitional care management services 
(99495) provided on January 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen allograft (20930). 
 
You asked the Plan to pre-approve ViviGen allograft. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested ViviGen allograft 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 ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ViviGen allograft (20930).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 12, 2022, 
through March 25, 2022. 
 
You asked the Plan to pay for the home health services. You say that the records support the billed HIPPS code 
2CB11. The Plan denied your request. The Plan says the records do not support the billed HIPPS code 2CB11.  
 
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 home health services. Our physician reviewer found the reviewed documentation did not support a qualifying inpatient facility stay. While the 
hospital documentation submitted has an admission date of March 10, 2022; the encounter information at the 
bottom of each hospital document states Observation. The review has determined that the medical records did 
not support the billed HIPPS code 2CB11. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from March 12, 2022, through March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Afrezza powder. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Afrezza powder.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.