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

We decided that the Plan does not have to pre-approve molecular pathology procedure level 1, MTHFR, F5, 
and F2 genetic testing services. 
 
You asked the Plan to pre-approve the molecular pathology procedure level 1, MTHFR, F5, and F2 genetic 
testing services. You say that the records provided support the need for the requested testing. The Plan denied 
your request. The Plan says the requested services are 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 molecular pathology procedure 
level 1, MTHFR, F5, and F2 genetic testing services. Our reviewer says that the requested molecular pathology 
procedure level 1, MTHFR, F5, and F2 genetic testing services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of a pulmonary embolism in 
2018 and has an elevated homocysteine level. On November 2, 2020, it is documented that, other than 
migraines, the enrollee is asymptomatic for the most part. The documentation does not support that the enrollee 
has an unusual circumstance where the requested F2 and F5 genetic testing will change her clinical 
management. The rules say that there is broad consensus in the medical literature that MTHFR genotyping has 
no clinical utility in any clinical scenario. This testing is considered investigational and is not a Medicare 
benefit. In addition, our physician reviewer found that the molecular pathology procedure level 1 is 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 the molecular pathology procedure level 1, MTHFR, F5, and F2 genetic testing 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve molecular 
pathology procedure level 1, MTHFR, F5, and F2 genetic testing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation at three levels bilaterally. 
 
You asked the Plan to pre-approve radiofrequency ablation at three levels bilaterally. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for 2 levels 
bilaterally. 
 
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 radiofrequency ablation at three levels 
bilaterally. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee 
had an epidural steroid injection which gave the enrollee 75% pain relief. The enrollee also takes Lyrica and 
Percocet for pain. Te enrollee underwent 2 sets of dual diagnostic medial branch blocks. The enrollee achieved 
greater than 80% pain relief with each set. The LCD utilization limits the request to 2 levels bilaterally. 
Therefore, only 2 levels of the 3 previously blocked are deemed 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 radiofrequency ablation at three levels bilaterally have not been met. Therefore, 
we decided that the Plan does not have to pre-approve radiofrequency ablation at three levels bilaterally.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 
documentation does support that the enrollee requires skilled nursing or skilled therapy services in the SNF 
setting. Our physician reviewer found the enrollee was admitted to the hospital with shortness of breath and 
loculated pleutal effusion treated with chest tube, oxygen, and physical therapy and occupational therapy. The 
chest tube was removed and the enrollee was noted to be stable but in need of additional daily physical therapy 
and occupational therapy. The documentation does support that the enrollee requires the specialized skills, 
knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment. The documentation does support that skilled nursing or skilled 
therapy services are required on a daily basis. As a practical matter, the enrollee does require the necessary 
services on an inpatient basis, at a SNF 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 SNF care have been met.  
 
The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the 
service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided 
that the Plan has to pre-approve skilled nursing facility (SNF) care.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after 
October 24, 2020. 
 
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 continued SNF coverage. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and insulin. The enrollee had stable vital signs. The enrollee was independent with bed mobility.  
The enrollee required supervision to moderate assistance with transfers. The enrollee was non-ambulatory. The 
documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a 
skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and 
reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are 
required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis, at a SNF 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 continued SNF coverage have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) coverage after October 24, 2020.
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 the clinical information provided 
supports the need for LTACH care. The Plan denied your request. The Plan says LTACH care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of morbid obesity, diabetes, hypertension, sarcoidosis, and 
sleep apnea, and was admitted to the acute care hospital on October 3, 2020, following a fall which resulted in 
multiple rib fractures and multiple lumbar transverse process fractures. The enrollee required intubation for 
acute hypoxic respiratory failure. A tracheostomy was placed on October 13, 2020. On November 2, 2020, the 
enrollee was on a 50% trach collar. The enrollee is receiving acute hospital care, and acute care services have 
not been denied. The documentation does not support that the enrollee in this case requires services at the 
LTACH that are not available at the acute care hospital where she is currently receiving 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 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) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for 
SNF care. The Plan denied your request. The Plan says admission to a SNF is not medically necessary. The 
Plan says that the enrollee is back to her prior level of functioning. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and was treated for a UTI. The enrollee was at a moderate to maximal assist 
level with bed mobility and transfers. She tolerated a regular diet and thin liquids. There are no identifiable 
skilled nursing service needs. There are no identifiable skilled therapy service needs. 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician's services that you provided on May 12, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
enrollee was in a hospice election period on this date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. It is the plan's position that the enrollee was enrolled in the Medicare 
hospice benefit on May 12, 2019, yet there is no evidence in the case file to support this as fact. To enroll in 
the Medicare hospice benefit, the enrollee (or valid representative) is required to sign a valid hospice benefit 
election document. Similarly, the enrollee is also required to sign a document to revoke the hospice benefit. 
Under Medicare rules, the hospice provider is required to file the hospice benefit election and/or revocation 
form with the Center for Medicare and Medicaid Services (CMS).  This information is reported in the Medicare 
enrollment data base under the Common Working File (CWF). The plan is required to provide this information 
as evidence that an enrollee has elected and/or revoked the Medicare hospice benefit.  In this case, the Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for physician's services provided on 
May 12, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from comprehensive 
therapy, rehabilitation nursing, and daily physical medicine and rehabilitation physician oversight at an 
inpatient rehabilitation facility. The Plan denied your request. The Plan says the guidelines for coverage of IRF 
care have not been met. The Plan says that the care needed could be received in 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 above. 
 
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 patient was 
admitted for deep vein thrombosis and presume pulmonary embolism. The enrollee's medical problems are 
stable. There are no identified problems that need inpatient medical management. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record 
supports a need for physical and occupational therapy, but it does not support a need for an intensive 
rehabilitation therapy program. 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. 
 
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: Partially Favorable

We decided that the Plan has to pay for the doppler echocardiography. We decided that the Plan does not have 
to pay for the anesthesia service.  
 
You asked the Plan to pay for the doppler echocardiography. You say that you would like reconsideration 
based on the records submitted. The Plan says that the documentation submitted does not support the service 
billed. 
 
We decided that the Plan has to pay for the doppler echocardiography.  
 
The Plan follows Medicare rules. Medicare rules say that  Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE). 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the doppler echocardiography have been met. Specifically, the Plan has not forwarded information 
on their decision regarding primary CPT code 93312. We are unable to make a decision on the add-on codes, 
93320 and 93325, without this information. It is the burden of the Medicare Health Plan to substantiate the 
denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided 
that the Plan has to pay for the doppler echocardiography.  
 
We also decided that the Plan does not have to pay for the anesthesia service. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Procedures 
should be reported with the CPT code that describes the services performed. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the anesthesia service. Our reviewer says that CPT code 
00562 does not meet criteria for billing or reimbursement consideration. Our reviewer found the record does 
not include an anesthesia report to verify the service 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 the anesthesia service have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia service. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has been in the hospital for over a month 
and needs physical therapy. You say that the enrollee is ready to be discharged to a rehab facility. The Plan 
denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says 
that the enrollee could receive care in 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 above. 
 
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 pseudoaneurysm of right groin with bleeding after coronary angiogram. He had hypoxemic 
respiratory failure. The enrollee's medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy, but it does not support a need for an intensive rehabilitation therapy program.  
 
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. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for this 
enrollee. The Plan denied your request. The Plan says ongoing care needs can be met 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 patient is currently undergoing treatment at an ACH for CoViD-19. The enrollee 
is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently 
available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute 
services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing 
needs. 
 
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.