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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 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 an LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 
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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the criteria for SNF care has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require daily skilled nursing or therapy services. The enrollee 
does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility 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 SNF care.
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 needs rehab because they need 
assistance to walk and caring for their personal needs of going to the bathroom. The Plan denied your request. 
The Plan says 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. 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. There is not a reasonable expectation that this 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 19, 2023, billed with 
codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81314, 81334, 81345, and 
81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. 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. 
 
The file shows that a comprehensive cancer panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single 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 April 19, 2023, billed with codes 81162, 81201, 81218, 81292, 
81295, 81298, 81307, 81317, 81321, 81351, 81314, 81334, 81345, and 81272.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dual-energy x-ray absorptiometry (DXA), bone density study 
(77080) provided on June 19, 2023. 
 
You asked the Plan to pay for the DXA. You say that medical records support code 77080 and should be paid. 
The Plan denied your request. The Plan says code 77080 was billed with modifier GZ; which is a Medicare 
non-covered service. 
 
The Plan must follow Medicare rules. The rules state that contractors will automatically deny services billed 
with modifier -GZ and will not perform complex medical reviews for these services.  
 
We find that payment for code 77080 is not supported. Specifically, modifier GZ identifies that the service is 
expected to be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the DXA have not been met. Therefore, we decided that the Plan does not have to pay for 
dual-energy x-ray absorptiometry (DXA), bone density study (77080) provided on June 19, 2023.
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 you are not able to walk properly and need to start 
therapy. You say that you are not able to go home and take care of yourself because of the issue with your hips. 
You say that you live alone. The Plan denied your request. The Plan says that admission to an IRF is not 
medically necessary and does not meet the criteria for coverage.  
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement. However, the documentation doesn't support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain your functional status. You can receive further 
services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power option (K0861) and additional items and accessories (codes E0953, E0955, E0960, E1012, E1028, 
E2300, E2311, E2359, E2377, E2620, and K0108). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power option and 
additional items and accessories. You say that the medical documentation which supports the need of the 
custom medical equipment being requested to be reviewed. The Plan denied your request. The Plan says the 
enrollee does not have medical need for multiple power options included with a K0861 Group 3 power 
wheelchair. The Plan also says an electronic connection, expandable controller harness, and expandable 
controller cannot be covered as it is not medically necessary to control the three requested power options 
through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
with multiple power option and additional items and accessories. Our reviewer says that the criteria for 
coverage have not been met. Our physician reviewer found the enrollee has chronic impairment from a spinal 
cord injury. The enrollee has 4 out of 5 strength in their upper extremities, a urostomy, and intact skin. Our 
reviewer also found that the enrollee does not have high risk for skin breakdown, use a catheter intermittently, 
have spasticity or require an alternative means of managing power drive. 
 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 Group 3 standard power wheelchair with multiple power option and additional 
items and 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) and additional items and accessories 
(codes E0953, E0955, E0960, E1012, E1028, E2300, E2311, E2359, E2377, E2620, and K0108).
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 will benefit from acute rehabilitation to 
optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says the 
enrollee's condition has improved, and they do not require an intensive team for their 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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
doesnt support that they would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week under the supervision of a physician with at least 3 visits weekly to regain or maintain 
her functional status. The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service August 17, 
2023. 
 
You asked the Plan to pay for procedure code 99152. You say that code 99152 is supported in the 
documentation. The Plan denied your request. The Plan says payment for code 99152 is bundled into payment 
for code 45380. 
 
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, we have confirmed that code 99152 is a column II code to column I code 45380. The medical 
records do not show that code 99152, billed with the -59 modifier, was a separate and distinct procedural 
service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99152 billed for date of service August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities, direct patient contact (97530) and self-
care/home management training (97535) provided from April 1, 2023, to April 28, 2023. 
 
You asked the Plan to pay for therapeutic activities and self-care/home management training. You say that you 
disagree with the denial and request payment on this claim. The Plan denied your request. The Plan says these 
codes are not appropriate for 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. 
 
 
 
 
 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 therapeutic activities and self-care/home management 
training. Our reviewer says that the service does not meet criteria for payment on this claim. Our reviewer 
found the codes in question for the dates of service are not supported. The record does not specify the time 
spent performing the components of the code descriptions. These are required elements to report these codes. 
Record does not support the services were performed as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic activities and self-care/home management training have not been 
met. Therefore, we decided that the Plan does not have to pay for therapeutic activities, direct patient contact 
(97530) and self-care/home management training (97535) provided from April 1, 2023, to April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with multiple 
power options (K0842) with power tilt and recline seating system. 
 
You asked the Plan to pre-approve the requested PWC. You say that it is felt that the requested PWC is 
required for the enrollee's mobility needs.  The Plan denied your request. The Plan says the criteria are not met 
in this case.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options may 
only be covered when the enrollee meets criteria for a power tilt and power recline seating system. 
 
 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 PWC. Our reviewer says 
that the criteria for the requested type of PWC have not been met.  Our physician reviewer found the enrollee 
has a history of obesity and osteoporosis complicated with Prader - Willi syndrome. She is dependent in some 
daily living activities but is able to transfer herself to the toilet. The documentation does not support that power 
tilt and recline is required since she does not have high risk for skin breakdown, does not use a catheter 
intermittently, and does not have spasticity.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested PWC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair (PWC) with multiple power options (K0842) with power 
tilt and recline seating system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis transmitter. 
 
You asked the Plan to pre-approve the Dexcom G6 Mis transmitter. You say that the medical records provided 
support the need for the requested Dexcom G6. The Plan denied your request. The Plan says Medicare 
Guidance says a continuous glucose monitor is covered under Medicare only if a member with diabetes is on 
insulin or has documentation of very low blood sugars that has occurred several times.  
 
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. Our reviewer says that 
this item is not medically necessary. 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 Medicare rules. The elements of the coverage criteria are not satisfied. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G6 Mis transmitter.
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 these services are medically necessary. 
The Plan denied your request. The Plan says these services can receive this care in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs this level of care. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the criteria for an SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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.