Persius/hicric huggingface dataset:
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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer may be considered when treatment has completed and long-term 
prognosis and care needs are more clear. 
 
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: 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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer to a lower level of care can be considered soon. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheter placement (93459), percutaneous transluminal 
revascularization (92941), critical care (99291), and moderate sedation services (99152) provided on August 
24, 2019. 
 
You asked the Plan to pay for catheter placement, percutaneous transluminal revascularization, critical care, 
and moderate sedation services. You say that this claim was billed correctly The Plan denied your request. The 
Plan says these codes are not supported in the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our 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 catheter placement, percutaneous 
transluminal revascularization, critical care, and moderate sedation services. Our reviewer says that these codes 
are not supported in the record. Our physician reviewer found CPT 93459 is not supported because the 
operative report does not include documentation to confirm catheter placement in coronary arteries for 
coronary angiography was provided. CPT 92941 is not supported because the operative report did not include 
revascularization coronary artery or coronary artery bypass graft. The documentation does not support 
evaluation and management of critically ill or critically injured patient first 30-74 minutes, meaning 99291 is 
not supported. The operative report does not include documentation of moderate sedation services, meaning 
99152 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of catheter placement, percutaneous transluminal revascularization, critical care, 
 
 
and moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
catheter placement (93459), percutaneous transluminal revascularization (92941), critical care (99291), and 
moderate sedation services (99152) provided on August 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Clarifix procedure (30117). 
 
You asked the Plan to pre-approve a Clarifix procedure. You say that this would benefit the enrollee. The Plan 
denied your request. The Plan says this is experimental. 
 
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 a Clarifix procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found here is a lack of evidence supporting the use of Clarifix for rhinitis and nasal congestion. The 
study that supports the use of cryotherapy is sponsored by Arrinex, which creates the Clarifix device. In 
addition, the patient has not met the typical criteria for this procedure. His nasal endoscopy exam did not show 
nasal discharge and he has not undergone treatment for vasomotor rhinitis. At this time the Clarifix procedure 
should be considered experimental and therefore is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Clarifix procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Clarifix procedure (30117).
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different 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 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 based on the medical records provided 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 may require skilled physical therapy and occupational therapy but 
based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging (MPI) spect rest/stress 
test (78452). 
 
You asked the Plan to pre-approve a MPI spect rest/stress test. 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 follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the 
presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or 
abnormalities on cardiac testing will be considered screening and denied as not covered by Medicare. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MPI spect rest/stress test. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the records 
the enrollee has no ischemic symptoms, a normal cardiac physical exam, no ischemic electrocardiographic 
changes and no ischemia on stress testing about 1 year ago. In this circumstance of a clinically stable enrollee 
with a recent favorable stress test the records do not support the medical necessity for nuclear stress testing. 
Coverage criteria are not met since there are no covered indications for the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MPI spect rest/stress test have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a myocardial perfusion imaging (MPI) spect rest/stress test (78452).
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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer can be considered soon when the enrollee's acute care treatment has 
completed. 
 
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: 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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has 
completed and it is appropriate. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 6, 2019. 
 
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 screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, Vitamin D assay and A1C testing, were requested solely for screening 
purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically 
necessary and expected to cross more than two midnights. The Plan denied your request. The Plan says that the 
enrollee can be treated in observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found it was reasonable that 2 or more midnights would be needed for this patient.  The 
patient was a harm to herself and others and could not be cared for at home.  Placement, Psychiatric, and Social 
evaluations 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and mandibular 
partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and 
teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you do not have any teeth and choke when 
you try to eat food. The Plan denied your request. The Plan says you exhausted your benefit. Medicare 
generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare 
coverage. For that reason, the Plan?s coverage rules apply in this case. Though the Plan offers a dental benefit 
in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. 
You were provided with immediate denture - maxillary (D5130) and D5214 on April 12, 2017. You had 
adjustments on May 26, 2017, May 31, 2017, and June 16, 2017, but have not been back since. The office also 
advised you may still go to the office to have the dentures evaluated since it?s been three (3) years and you will 
most likely need to have a reline done. The health plan contract says Complete dentures (upper and lower) 
(One (1) upper complete and one lower complete denture every five (5) years, including routine post-delivery 
care) or Partial dentures (upper and lower) (One upper and/or one lower partial denture every five years, 
including routine post-delivery care). Denture reline (One procedure per calendar year). Therefore, we decided 
that the Plan does not have to pre-approve complete denture - maxillary (D5110) and mandibular partial 
denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 
(D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of a substance into the nerves of the hip 
region, guided by picture studies, to diagnose or treat pain. 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says research has not proven this service to be helpful and it is considered experimental or 
investigational. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental/ investigational due to the wide variation in efficacy 
in the peer reviewed literature. Therefore, the request is deemed 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection of a substance into the nerves of the hip region, guided by picture studies, to 
diagnose or treat pain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (20680, 29826, 29827) provided February 
7, 2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation provided does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 20680, 29826, & 29827 is not supported in the medical record. Specifically, the 
operative report documents an open rotator cuff repair, therefore an arthroscopy rotator cuff repair cannot be 
confirmed. The operative report does not include partial acromioplasty. Documentation does not support 
removal of implant as a separate procedure. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services (20680, 29826, 29827) provided February 7, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from July 
2, 2019, to July 12, 2019. 
 
You asked the Plan to pay for the SNF services. You say that it is felt that these services were medically 
necessary. The Plan denied your request. The Plan says the Medicare SNF criteria are not met. 
 
 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 87-year-old female 
with anemia and GI bleed. From a nursing perspective, the beneficiary received oral medications. The 
beneficiary had stable vital signs. She used oxygen via nasal cannula. Regarding rehabilitation services, the 
beneficiary received PT and OT in the SNF. By the dates in question, the beneficiary was at a stand-by assist 
level with functional mobility including gait to 200 feet with a rolling walker. The beneficiary required varying 
assist with ADLs. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, these do not require daily skilled therapy services. This beneficiary does not meet 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 pay for the skilled nursing facility (SNF) services provided from July 2, 2019, to July 12, 2019.