Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liver transplantation. 
 
You asked the Plan to pre-approve liver transplantation. You say that liver transplantation is medically 
necessary. The Plan denied your request. The Plan says liver transplantation is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that liver transplantation is covered when the criteria 
listed in the Medicare rules section of this decision are met. 
 
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 liver transplantation. Our reviewer says 
that the requested liver transplantation is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee with hepatocellular carcinoma secondary to fatty liver disease. The 
reasons for denial of request for liver transplantation include extensive atherosclerosis and heart disease, as 
well as concern for potential sigmoid neoplasm that has not yet been addressed. The first two components 
(atherosclerosis and heart disease) are not absolute contraindications of liver transplant, nor are the enrollees 
other comorbidities (history of abdominal aortic aneurysm repair, chronic kidney disease). Pending the results 
of a workup for the positron emission tomography (PET)-avid area in the sigmoid colon, the enrollees other 
conditions would not be absolute contraindications to liver transplantation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of liver transplantation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve liver transplantation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (0775T). 
 
You asked the Plan to pre-approve SI joint fusion. You say that this device will address the enrollee's chronic 
pain. The Plan denied your request. The Plan says the clinical value and effectiveness of this procedure in the 
setting of sacroiliac joint pain and sacroiliitis have not been demonstrated in the peer-reviewed literature. 
 
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 SI joint fusion. 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 SI joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental and investigational. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (0775T).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered COVID-19 test (K1034) provided on 
June 27, 2023. 
 
You asked the Plan to pay for the self-administered COVID-19 test. You say that this should be reprocessed 
and paid. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the self-
administered COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the 
self-administered COVID-19 test (K1034) provided on June 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over the counter (OTC) COVID-19 test (K1034) 
provided on July 12, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that this should be reprocessed and paid. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the over the 
counter (OTC) COVID-19 test (K1034) provided on July 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 29, 2023, to May 
28, 2023. 
 You asked the Plan to pay for the home health services. You say that the required NOA has been submitted and 
accepted. 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 February 28, 2023. The NOA was not received by the Plan until June 29, 
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 home health services provided 
from April 29, 2023, to May 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service July 12, 
2023. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17250 billed for date of service April 6, 
2023, to April 27, 2023. 
 
You asked the Plan to pay for procedure code 17250. The Plan denied your request. The Plan says payment for 
code 17250 is bundled into payment for code 11043. 
 
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 17250 is a column II code to column I code 11043. The medical 
records do not show that code 17250, billed with the -59 modifier, was a 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 17250 billed for date of service April 6, 2023, to April 27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services coded as 99283 and the 
application of a short arm splint coded as 29125 performed on November 2, 2022.  
 
You asked the Plan to pay for 99283 and 29125. You say that 99283 and 29125 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says that 29125 is 
recoded to 01860 because the primary taxonomy of the billing group for this claim is Anesthesiology. 99283 is 
denied because payment for this service would be bundled into payment for code 01860. 01860 is denied 
because it was not billed with an anesthesia modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say a significant and separately 
identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately 
reportable with modifier -25. 
 
We looked at the file and Medicare rules. While the billing group in this case has Anesthesiology as their 
primary taxonomy, this is not sufficient to determine that the rendering provider can only be paid for anesthesia 
codes. In this case, records do not support that anesthesia services were provided, so recoding 29125 to 
anesthesia code 01860 is not appropriate. Documentation instead supports the application of short arm splint 
was performed, therefore, 29125 is supported in the record. In this case, 99283 was billed with modifier -25 to 
allow for separate payment on the same date as the procedure coded as 29125. 29125 has a global surgery 
indicator of 000, meaning it is considered a minor procedure. A significant and separately identifiable E&M 
service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 
-25. Records in this case support that the E&M services provided to the enrollee in the emergency department included evaluation and treatment for an open cat bite on the head unrelated to the evaluation and treatment of 
the injury to the hand that resulted in the application of a splint. Therefore, 99283 billed with modifier -25 is 
supported. Based on this information, we decided that Medicare rules for coverage of 99283 and 29125 have 
been met. Therefore, we decided that the Plan has to pay for the evaluation and management services coded as 
99283 and the application of a short arm splint coded as 29125 performed on November 2, 2022.   
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ogivri. 
 You asked the Plan to pre-approve Ogivri. You say that the requested injection is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee did not meet the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 injections. Our physician reviewer 
found that the Plan requires a trial of Kanjinti or Trazimer before they will approve Ogivri. Our physician 
reviewer found that based on the medical records provided there is no indication that the enrollee has tried and 
failed the required drugs. Our physician reviewer found that there is no indication that the Plans required drugs 
would likely be less effective and/or likely have adverse effects 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 Ogivri have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ogivri.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient rehabilitation facility (IRF) services provided 
from May 16, 2023, through June 14, 2023. 
 
You asked the Plan to pay for the IRF services. You say that this was billed correctly and should be paid.  The 
Plan denied your request. The Plan says this claim was not billed correctly for an IRF. 
 
The Plan must follow Medicare rules. Medicare rules say that IRF claims are to report a HIPPS code on 
revenue code 0024 to identify the payment classification for the services rendered.  
 
 We looked at the file and Medicare rules. Review of the claim reveals that revenue code 0024 was not reported 
as required, nor was the HIPPS code. Based on this information, we decided that Medicare rules for coverage 
of the IRF services have not been met. Therefore, we decided that the Plan does not have to pay for the 
inpatient rehabilitation facility (IRF) services provided from May 16, 2023, through June 14, 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 if the patient goes to a lower level of rehabilitation, it 
will compromise them achieving the highest level of functional outcome. You also say that you would like the 
IRF service to be reconsidered. The Plan denied your request. The Plan says based on Medicare guidelines, the 
IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found 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. Our physician reviewer also found that 
there is not a reasonable expectation that this patient 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: 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 as she had surgery to 
her hip and is not able to use a walker correctly or fully walk on her own. 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 enrollees nursing, medical, and rehabilitation needs does 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. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation 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 wound care supplies coded as A6222, A6446 and A4450 
provided on July 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care supplies. You say that  these supplies are a separately billable 
expense that does not require separate authorization and have not been included in any other billing to treat 
wounds described in the attached medical records. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered.  
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 wound care supplies coded as A6222, A6446 
and A4450 provided on July 19, 2023, by an out-of-network (OON) provider.
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 for the denial of 
acute inpatient 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81479) provided 
October 20, 2022. 
 You asked the Plan to pay for the genetic testing. You say that you request reconsideration of the denial. This 
decision is incorrect based on current publications and medical practice. The Plan denied your request. The 
Plan says this test is not medically necessary and not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per DEX Diagnostics, this test is not covered by Medicare. 
GeneSight Psychotropic test is a combinatorial pharmacogenomic test which per the LCD is not medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing 
(81479) provided October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) COVID-19 test provided on July 
3, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. The Plan denied your request. The Plan says OTC 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for OTC items, including 
self-administered COVID-19 tests. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an over-the-counter (OTC) COVID-19 test provided on July 3, 2023.