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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the inpatient rehabilitation facility 
to return home safely and have maximal improvement. The Plan denied your request. The Plan says the 
inpatient rehabilitation facility services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical 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 Tempus xT testing (81456) provided on June 22, 2023. 
 
You asked the Plan to pay for the Tempus xT testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case the records do not show that the enrollee has recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we decided that 
Medicare rules for coverage of the Tempus xT testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus xT testing (81456) provided on June 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Tecentriq. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Tecentriq is medically reasonable and necessary or safe and effective 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table. 
 
You asked the Plan to pre-approve an over-bed table. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table.
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 this care to regain maximum 
function. The Plan denied your request. The Plan says medical records do not support the need for an IRF 
admission and, the enrollee needs can be provided at another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93305 billed for date of service June 1, 2023. 
 
You asked the Plan to pay for the billed service. You say that this service is covered by the fee schedule. The 
Plan denied your request. The Plan says the service is not separately payable. 
 
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 CPT code 93305 has a status indicator of Q1. This code is not separately payable as it was billed 
with code 99284, which has a status indicator of V. Based on this information, we decided that Medicare rules 
for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 93305 billed for date of service June 1, 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 the enrollee needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction equipment (E0849) provided on June 26, 
2023. 
 
You asked the Plan to pay for the cervical traction equipment (E0849). You say that the provided cervical 
traction equipment (E0849) was medically necessary.  The Plan denied your request. The Plan says the enrollee 
did not meet criteria for the provided cervical traction equipment (E0849). 
 
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 pay for the cervical traction equipment (E0849). Our 
reviewer says that the enrollee did not meet criteria for the provided cervical traction equipment (E0849). Our 
physician reviewer found the documentation does not reveal subjective and objective indications of a 
musculoskeletal or neurologic impairment requiring traction equipment and that the appropriate use of a home 
cervical traction device has been demonstrated to the enrollee and the enrollee tolerated the selected device. 
 
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 cervical traction equipment (E0849) have not been met. Therefore, we 
decided that the Plan does not have to pay for the cervical traction equipment (E0849) provided on June 26, 
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 were independent and active before coming to 
the hospital and wish to return to being independent as quickly as possible. The Plan denied your request. The 
Plan says the enrollee's condition does not meet all of the requirements for inpatient rehabilitation admission. 
The Plan says services may be provided at 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 your 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, custom wheelchair. 
 
You asked the Plan to pre-approve a heavy duty, custom wheelchair. You say that the enrollee wants this item 
since it is easier to move inside his home by himself. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
 
 
 The item being requested shows to be for replacement of an identical or nearly identical item. The case file 
shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due 
to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-approve a heavy 
duty, custom wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that this is a covered test. The Plan denied your request. 
The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rexulti (brexpiprazole) tablets. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has Alzheimer's with severe 
agitation and aggressive behaviors. 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 Rexulti (brexpiprazole) 
tablets.
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 requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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. 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 no 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73551-26-RT billed for date of service 
February 18, 2023. 
 You asked the Plan to pay for procedure code 73551-26-RT. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 73551-26-RT is bundled into 
payment for code 73552-26-RT. 
 
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 
73551-26-RT is a column II code to column I code 73552-26-RT. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 73551-26-RT billed for date 
of service February 18, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are necessary. 
The Plan denied your request. The Plan says you do not meet the criteria for the additional PT visits. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to provide treatment safely and effectively, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. You have had ample approved 
therapy already and should be able to transition safely to a home exercise program. The requested additional 
therapy sessions 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 24 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve injection of sclerosant; single incompetent vein (36470). 
 
You asked the Plan to pre-approve sclerotherapy. You say that the enrollee underwent right greater saphenous 
vein (GSV) radiofrequency ablation (RFA) in 2012. You also say that in the last two years the enrollee has had 
worsening right leg edema, tender varicosities, and limiting heaviness/pain in the leg. The Plan denied your 
request. The Plan says that the records do not show that the enrollee's veins are greater than 4 mm. The Plan 
also says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if the veins are at least 4 millimeters (mm) in diameter 
 
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 sclerotherapy. Our reviewer says that 
the requested sclerotherapy is medically necessary. Our physician reviewer found the patient is having activity 
limiting symptoms attributable to the varicose veins in question. Palpable pedal pulses are documented. There 
is documentation that the saphenous reflux has been previously treated, and that the patients significant 
symptoms persist despite more than several months of conservative efforts including compression 
stockings. The medical record documentation of large prominent varicose veins is satisfactory documentation 
that the varicosities are larger than 4 millimeters (mm) in diameter in the context of this review. Therefore, the 
reviewer found that the requested sclerotherapy is 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 sclerotherapy have been met. Therefore, we decided that the Plan has to pre-
approve injection of sclerosant; single incompetent vein (36470).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90471 and 90714 for date of service May 
30, 2023. 
 
You asked the Plan to pay for procedure codes 90471 and 90714. 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 CPT codes 90471 and 90714 are not payable as billed. Specifically, code 90471 has a status 
indicator of Q1. Procedure code 99283 was billed on the same claim, with the same date of service, with a 
revenue code of 450. This gives code 99283 a status indicator of V (clinic or emergency department visit). 
Therefore, procedure code 90471, which has a status indicator of Q1, is not separately payable. In addition, 
code 90714 has a status indicator of N. Codes with status indicators of N are never separately payable. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 90471 and 90714 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 90471 and 90714 for 
date of service May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT testing (81456) provided on June 1, 2023. 
 
You asked the Plan to pay for the Tempus xT testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case the records do not show that the enrollee has recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we decided that 
Medicare rules for coverage of the Tempus xT testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus xT testing (81456) provided on June 1, 2023.