Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide facet joint injections. 
 
You asked the Plan to provide destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional 
facet joint (64636). You say that the enrollee needs facet joint injections for pain relief. The Plan denied your 
request. The Plan says criteria is not met for facet joint injections. 
 
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 provide destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet 
joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, each additional facet joint (64636). Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
patient has other probable pain generators and radicular pain symptoms. Therefore, the patient does not meet 
the criteria of the LCD.  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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional 
facet joint (64636) have not been met. Therefore, we decided that the Plan does not have to provide facet joint 
injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 27, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the cardiovascular testing was 
done during the same office visit. You say that you should have no cost share responsibility. The Plan denied 
your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 for 
each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor?s office visits" benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit provided on November 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of inpatient skilled nursing facility care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that at the time 
of discharge from skilled care the enrollee had stabilized medically and had a functional plateau. The enrollee 
did not require any skilled nursing or rehabilitation services on a daily basis at an inpatient level of care. She 
was not expected to make measurable gains within a reasonable and predictable period of time or require 
skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require 
skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not 
require any skilled services on an inpatient basis, at a SNF level of care after discharge from skilled care in 
December of 2020. The enrollee did not have any parental medication, complex wound care or nutrition given 
via a feeding tube. She has been medically stable without any acute exacerbations of chronic medical problems.  
Additionally, the enrollee's physical function is at her new baseline and she can receive further services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no 
complex wound care or other skilled nursing need. His pressure injuries to the coccyx do not require a SNF 
admission. The enrollee's high functional level does not require skilled therapy services with the specialized 
skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically 
necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a daily 
basis or as a practical matter on 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve insertion of pacemaker pulse generator system only (33225). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that the denial of cardiac resynchronization therapy (CRT) 
pacemaker/biventricular pacer was appropriate given the clinical scenario and guidance. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. This patient has a 
complex history of recurrent atrial fib/flutter and has failed medical, surgical and ablative therapies with 
recurrent symptoms and rapid atrial fibrillation recurrence. She has been referred for atrioventricular nodal 
ablation as a more last resort procedure to stop the recurrent symptomatic rapid a trial fibrillation. 
 
This planned ablation will result in complete (3rd degree) heart block when this is carried out and the enrollee 
will require a pacemaker to maintain a ventricular cardiac rhythm. The pacemaker is being placed in response 
to the planned medically induced 3rd degree heart block from the atrioventricular nodal ablation. Our physician 
reviewer found that the enrollee's condition meets Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve insertion of pacemaker pulse generator system only (33225).  
 
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 
enrollee does not meet criteria for IRF admission. 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 COVID-19 pneumonia, 
respiratory failure, gastrointestinal bleeding and acute kidney injury. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
 
  
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the punch graft hair transplant provided on October 22, 2020.
You asked the Plan to pay for the punch graft hair transplant. The Plan denied your request. The Plan says cosmetic procedures are not covered.
The Plan follows Medicare rules. Medicare rules say that punch graft hair transplant may be considered reconstructive when it is performed for eyebrow(s) replacement following a burn injury or tumor removal. 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 punch graft hair transplant. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found that in this case, punch graft hair transplant is being used for frontal fibrosing alopecia of the frontal hairline. The criteria of the local coverage determination are not satisfied.
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 punch graft hair transplant have not been met. Therefore, we decided that the Plan does not have to pay for the punch graft hair transplant provided on October 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine mileage, per trip (A0170). 
 
You asked the Plan to pre-approve the additional mileage. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable 
transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the Plan's rules. Based on this information, we 
decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, your 
request submitted to the Plan was for a total of 300 miles for each trip. However, the Plan contract provides 
coverage for 50 miles only of driving distance for each trip. Your request exceeds the allowable transportation 
benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine mileage, per trip 
(A0170).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for 4 additional units of CPT 97110 provided on October 17, 
2019. 
 
You asked the Plan to pay for the additional units. The Plan denied your request. The Plan says only 4 units of 
this service are supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure 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 the additional units Our reviewer says that 4 
additional units (8 total units) of CPT 97110 are not supported by the records provided. Our physician reviewer 
found that CPT 97110 describes therapeutic exercises that a patient participates in during an OT therapy 
session. The total documented in-home time on October 17, 2019 was 0.98 hours. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for 4 additional units of CPT 97110 provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
2, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you were informed there 
would not be a lab copayment during an office visit. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 for 
Medicare-covered laboratory tests. 
 
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Laboratory services are not 
included in the annual physical or annual wellness visit benefit. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for laboratory services provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sympathetic nerve block injection. 
 
You asked the Plan to pre-approve nerve block. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because this procedure is 
experimental/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 nerve block. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documented physical examination does not include range of motion limitation detail or 
facet loading tests. You had facet joint injections, but the duration and degree of pain relief are not clearly 
delineated. There is no detail of any sympathetic symptoms or physical findings. There is no detail of sciatic 
pain or of a proposed therapy. The procedure code requested does not correspond to either sympathetic block, 
peripheral nerve block, or a facet block. There is no detail to support any procedure at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sympathetic nerve block injection.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that your needs can be done at a skilled nursing facility. 
 
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. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. Our physician reviewer found 
that your condition does not meet Medicare criteria for LTACH services. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 
enrollee does not meet criteria for IRF admission. 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 surgical repair of a hip fracture 
after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral breast MRI with and without contrast. 
 
You asked the Plan to pre-approve a bilateral breast MRI with and without contrast. You say that the requested 
bilateral breast MRI with and without contrast is medically necessary. The Plan denied your request. The Plan 
says the requested bilateral breast MRI with and without contrast is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bilateral breast MRI with and without 
contrast. Our reviewer says that the requested bilateral breast MRI with and without contrast is not medically 
necessary. Our physician reviewer found the enrollee would like an MRI screening for breast cancer because of 
pain with mammograms and history of breast cancer in the family. Per the American Society of Breast 
Surgeons Consensus guidelines, MRI screening of breasts are indicated for patients with BRCA+, other germ 
line mutations, history of chest irradiation, and having a greater than 20% risk of developing breast cancer. In 
this case, the documentation notes the enrollee's risk is 15-18%. The requested bilateral breast MRI is not 
medically necessary at this time. 
 
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 bilateral breast MRI with and without contrast have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a bilateral breast MRI with and without contrast.