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

We decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) provided on 
March 3, 2020. 
 
You asked the Plan to pay for the adjacent tissue transfer. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted 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. 
 
In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. 
 
The CPT Code Manual definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each 
additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 
 
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 adjacent tissue transfer. Our reviewer says that CPT 
codes 14301 and 14302 do not meet criteria for billing or reimbursement consideration. Our reviewer found the 
medical records submitted do not include sufficient documentation to validate that an Adjacent tissue transfer 
or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm was performed on March 3, 2020, therefore this 
service cannot be verified. The medical records provided documents that "total undermining of skin measuring 
12 x 11cm" was performed.  Undermining alone of adjacent tissues to achieve closure, without additional 
incisions, does not constitute adjacent tissue transfer. 
 
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 adjacent tissue transfer have not been met. Therefore, we decided that the 
Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) provided on March 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 records show that this patient is improving and although requires additional short 
term acute care for additional stabilization and treatment, this is likely to take less than 25 days, and could 
safely be completed at the current facility. The patient does not require services at the LTACH that are not 
already available at the current setting. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current setting. Therefore, this request for LTACH services will be 
considered not medically necessary. Transfer to a lower level of care may 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient hospital level of care. 
 
You asked the Plan to pre-approve the inpatient level of care. You say that you haven't left the hospital since 
November 6th and are receiving a blood transfusion. The Plan denied your request. The Plan says that there is 
no medical necessity for inpatient admission and that the enrollee is medically stable for discharge to home or a 
lower level of care. 
 
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 the inpatient level of care. Our reviewer 
says that an inpatient level of care is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was admitted after coming to the emergency department with a hip injury and the 
inability to ambulate or safely go in and out of home. The enrollee had several other abnormalities such as 
anemia, requiring transfusion. The enrollee is apparently still in the hospital. Given the enrollee's age and 
comorbid conditions, as well as her degree of disability with acute injury, admission is medically necessary and 
indicated. 
 
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 inpatient level of care have been met. Therefore, we decided that the Plan 
has to pre-approve an inpatient hospital level of 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: 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 documentation provided, the health plan's denial should be upheld. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The enrollee's 
care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 the device. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the CardioMems device is FDA approved to prevent recurrent hospitalizations in patients with Class III 
CHF and this condition and has also been shown to assist in management of both chronic systolic failure and 
heart failure with preserved ejection fraction. The enrollee's heart disease is quite complex with both pre and 
post capillary pulmonary hypertension contributing to her symptoms. Optimization of cardiac filling pressures 
to manage diuretics and other cardiac medications is critical and Cardiomems has published literature and an 
FDA indication for the management of congestive failure and is especially useful in these very complex 
clinical situations. It is medically necessary and appropriate for the management of this complex clinical 
situation and is not investigational for this purpose. 
 
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 device have been met. Therefore, we decided that the Plan has to pre-
approve the CardioMEMS device for the enrollee.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 records show that you are tolerating weaning and although require additional 
short term acute care for additional weaning and treatment, this is likely to take less than 25 days, and could 
safely be completed at the current facility. You do not require services at the LTACH that are not already 
available at the current setting. There are no services at the LTACH that you require that are not already 
available and covered at the current setting. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer to a lower level of care may be considered when 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presented with complaints of grade 5-6/10 left hip and buttocks pain. She reported increased 
pain with walking and sitting. She has a history of neurogenic claudication. There is reported MRI evidence of 
severe L4/5 central canal stenosis and severe left L4/5 and L5/S1 neuroforaminal stenosis. She has failed to 
achieve adequate relief with activity modification, medications, and multiple injections. Under consideration is 
a request for L4/5 Vertiflex Superion interspinous device. Current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of 
lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of this device for this enrollee's medical condition as discussed above. FDA indications include 
implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal 
stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has 
severe L4/5 central canal stenosis and severe left L4/5 and L5/S1 neuroforaminal stenosis, and would not meet 
FDA indications. FDA contraindications include obesity and osteoporosis, that have not been adequately 
addressed in the medical records. There is no documentation of the enrollee's height, weight or body mass 
index. 
 
 
 
There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this post-menopausal 
86-year-old female. Vertiflex Superion indirect lumbar decompression would not be considered the standard of 
care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically 
reasonable and necessary for treatment of this enrollee's medical condition. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion interspinous device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation (64625). 
 
You asked the Plan to pre-approve cooled radiofrequency ablation. You say that you have received these 
procedures in the past and they have improved your quality of life. The Plan denied your request. The Plan says 
this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that non-thermal RF modalities for facet joint 
denervation including chemical, low grade thermal energy (under 80 degrees Celsius), as well as pulsed RF are 
not covered. 
 
We looked at the file and Medicare rules. The requested service is excluded from covered. Based on this 
information, we decided that Medicare rules for coverage of cooled radiofrequency ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency ablation (64625).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on May 12, 2020 
billed with 81 units of code 97161 and 65 units of 97110 and the services provided on May 14, 2020 billed 
with 60 units of code 97110. 
 
You asked the Plan to pay for the physical therapy services as billed. You say that the number of units shown 
on the remittance are not what was billed for those dates of service and the medical records show what was 
provided. The Plan denied your request. The Plan says the claim received was billed with excessive units and 
cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
In this case, the claims do not report a number of units which matches the services provided. A corrected claim 
with the actual number of units would be necessary. Therefore, we decided that the Plan does not have to pay 
for the physical therapy services provided on May 12, 2020 billed with 81 units of code 97161 and 65 units of 
97110 and the services provided on May 14, 2020 billed with 60 units of code 97110.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested external drug infusion pump and supplies. 
 
You asked the Plan to pre-approve external drug infusion pump and supplies. The Plan denied your request. 
The Plan says your records do not show a reason for care outside of your established health network. Your 
current medical problems can be safely managed within the network.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve the requested 
external drug infusion pump and supplies.
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 IRF care would be the optimal level of care for this 
enrollee. The Plan denied your request. The Plan says there is no need for intensive therapies or frequent 
physician supervision in the hospital 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 enrollee was admitted on 10/27/2020 for quadruple coronary bypass and aortic 
valve replacement. The enrollee has progressed with therapy and, as of 11/9/2020, is walking up to 75 feet with 
minimal assistance. The enrollee does not require the intensity of services provided at an IRF. Specifically, the 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography of the heart with quantitative 
evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve this service. You say that computed tomography of the heart is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of 
this service. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, your request includes quantitative calcium scoring 
which is not a covered benefit by Medicare and is deemed as not medically necessary. Therefore, we decided 
that the Plan does not have to pre-approve computed tomography of the heart with quantitative evaluation of 
coronary calcium (75571).
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 the SNF admission. You say that the enrollee would benefit from skilled 
services on a daily basis. The Plan denied your request. The Plan says the enrollee's needs are custodial and can 
be met with less than daily skilled care. 
 
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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 77-year-old 
female with a diabetes, dementia, vulvar abscess and bilateral below-knee amputations. From a nursing 
perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She was 
diagnosed with cervical stenosis. She had routine Foley catheter care. Her lungs were clear. Regarding 
rehabilitation services, the beneficiary received PT in the acute hospital. The beneficiary required total assist 
for bed mobility.   
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
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 admission 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a second 
opinion. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says your prostate cancer can be managed within the primary network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider for a second opinion.