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

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on August 17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the requested testing is payable by Medicare, 
and they were denied as experimental in error. The provider has attached medical records for review. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested testing. 
 
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. Molecular NGS testing alone (for myeloid mutations) or in 
combination with FISH testing is not reasonable and necessary for the diagnosis of MDS and is not a Medicare 
benefit. NGS testing is not covered as part of an anemia work-up. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (81455) provided on August 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix, per sq cm (Q4186). 
 
You asked the Plan to pre-approve Epifix. 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 Epifix. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that records do not show that this request is for a standard of care, 
reasonable use. The provider is planning to use this as part of his Mohs surgery. The review has determined 
that the items/services at issue in this case are 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 Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix, per sq cm (Q4186).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that you 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing room and board provided from January 1, 
2023, to January 4, 2023. 
 You asked the Plan to pay for the skilled nursing room and board. You say that room and board for a hospice 
patient in a skilled nursing facility is never submitted to Medicare. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing room and board provided from January 1, 
2023, to January 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 30, 
2022, to December 1, 2022. 
 
You asked the Plan to pay for SNF care. You say that the provider is approved by the state as a skilled nursing 
facility. You were released from the hospital to this facility. The Plan denied your request. The Plan says the 
provider is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for skilled 
nursing facility (SNF) care provided from April 30, 2022, to December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections.  
 
You asked the Plan to pre-approve epidural steroid injections. You say that epidural steroid injections are 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injections do 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injections. Our 
reviewer says that the requested epidural steroid injections are not considered medically necessary in this case. 
Our physician reviewer found that on April 18, 2023, the enrollee received an L4-L5 interlaminar epidural 
steroid injection. The enrollee had 50-60% pain relief for four (4) weeks. The request is to repeat the ESI at the 
same level and same approach. The Medicare LCD criteria requires three (3) months of 50% pain relief to be 
considered a successful block. Therefore, the request is deemed not medically reasonable and 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Electrical Nerve Stimulation. 
 
You asked the Plan to pre-approve Percutaneous Electrical Nerve Stimulation. You say that Percutaneous 
Electrical Nerve Stimulation is medically necessary. The Plan denied your request. The Plan says the requested 
Percutaneous Electrical Nerve Stimulation does not meet the Medicare coverage criteria.  
 
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 Percutaneous Electrical Nerve 
Stimulation. Our reviewer says that the requested Percutaneous Electrical Nerve Stimulation is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has left foot 
and ankle pain due to osteoarthritis. The enrollee has tried Gabapentin, Lyrica, Baclofen, Tizanidine and 
Diclofenac. The request is for placement of a Freedom peripheral nerve stimulator. This is considered experimental and therefore, the request is deemed not medically reasonable and 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 Percutaneous Electrical Nerve Stimulation  have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Percutaneous Electrical Nerve Stimulation.
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 you are requesting reconsideration of the 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 that the documentation does not support that you require active and ongoing 
therapeutic intervention of multiple therapy disciplines. The provided physical therapy and occupational 
therapy notes recommend care 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87651, 87641) provided on 
March 2, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you do not agree with the denial and request 
payment on the claim. The Plan denied your request. The Plan says specific information needed was requested 
and not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. The 
records show the Plan requested treatment records which should have included laboratory results and copies of 
order from referring physician and/or documentation that supports the necessity of the tests performed. These 
documents were not received. Therefore, we decided that the Plan does not have to pay for laboratory services 
(87481, 87651, 87641) provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) Mis 
Sensor. You asked the Plan to pre-approve a Dexcom G6 CGM Sensor. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the provided records indicate that the enrollee is not on insulin, and 
that there is no indication that hypoglycemia has occurred or is a clinical concern. The enrollee does not meet 
criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G6 CGM Sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 continuous glucose monitor (CGM) Mis Sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
January 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on December 29, 2022. 
 
You asked the Plan to pay for the medication. You say that you waited 7 hours in the waiting room before 
receiving the medication. 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 pay for self-administered drugs provided 
on December 29, 2022.  
 
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.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the IRF benefit within Medicare is precisely intended to ensure the full and prompt recovery of enrollees 
such as this one, who risk not being successful in lesser care settings. Therefore, the requested inpatient 
rehabilitation facility admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that you are in a lot of pain and that 
this epidural steroid injection helped provide you with pain relief that lasted nine months. You say that now the 
pain has returned, and you would like a repeat injection. The Plan denied your request. The Plan says that the 
Plan did not receive any additional notes from your doctor that document you had at least 50% pain relief that 
lasted at least three months. 
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is considered medically necessary. Our physician 
reviewer found that you have chronic neck and low back pain. You had bilateral L5 selective nerve root 
injections on July 1, 2022. When evaluated soon thereafter, you had 80% pain relief. An office note of  
May 23, 2023, states that you had 80-100% pain relief for nine (9) months and request a repeat ESI. The 
request meets the Medicare LCD criteria and is medically reasonable and 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
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 the continuation of inpatient hospital care from June 19, 
2023, and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient hospital care from June 19, 2023, and forward. 
You say that the continuation of inpatient hospital care from June 19, 2023, and forward is medically 
necessary. The Plan denied your request. The Plan says the continuation of inpatient hospital care from June 
19, 2023, and forward is not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continuation of inpatient hospital 
care from June 19, 2023, and forward. Our reviewer says that the continuation of inpatient hospital care from 
June 19, 2023, and forward is not medically necessary. Our physician reviewer found the enrollee was admitted 
to the hospital on June 14, 2023, with falls and evidence of widespread metastatic disease, likely of a prostate 
origin. He had severe pain which was treated with opioids, and steroids were initiated along with Degarelix. 
Urology, Medical Oncology, Neurosurgery, Radiation Oncology, Orthopedic surgery, Physical therapy, Wound 
care, Physical Medicine and Rehabilitation (PM&R), and Addiction Medicine services were consulted. His 
prostate biopsy was delayed until June 20, 2023, and this confirmed prostate adenocarcinoma. The enrollee 
waited several days until a magnetic resonance imaging (MRI) study could be performed on or around June 23, 
2023. In addition, another 5 days passed before he had radiation therapy on June 28, 2023. There were 
considerations for both subacute rehab in the skilled nursing facility (SNF) environment versus home with 
home health care. The physical therapist recommended that the enrollee go home. There were significant 
delays in the enrollee's care which resulted in a prolonged hospitalization. The review has determined that the 
continuation of inpatient hospital care from June 19, 2023, and forward was not medically reasonable and 
necessary for the enrollee in this case. 
 
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 continuation of inpatient hospital care from June 19, 2023, and forward have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient 
hospital care from June 19, 2023, and forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services billed with code 88305 on 
October 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the surgical pathology services billed with code 88305 on 
October 11, 2022.