Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care from November 18, 2020, through November 23, 2020.

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 the complexity of the patient'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 surgical repair of a hip fracture after a fall. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient 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 this patient 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 IRF care from November 18, 2020, through November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for when 
there is no ulcers or for edema. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intrarosa. 
 
You asked the Plan to pre-approve Intrarosa. You say that you want the enrollee treated with this drug. The 
Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Intrarosa.  
 
Benefits for Intrarosa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiography (TTE) test. 
 
You asked the Plan to pre-approve TTE test. You say that you are unsure why this would not be approved and 
want to use this to diagnose mild aortic stenosis. The Plan denied your request. The Plan says that the denial of 
authorization for this service is correct, because the records do not show why this test is needed. 
 
The Plan follows Medicare rules. Medicare rules say that TTE is covered for certain indications including 
evaluation of native valvular heart disease. 
 
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 TTE test. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested TTE test. Our physician reviewer found according to the 
documentation the enrollee has no symptoms of chest pain, shortness of breath, or syncope. The last 
echocardiograph was in 2018. The enrollee meets the coverage indications for this TTE test. The enrollee does 
not meet any exclusions/limitations for this request. The requested TTE test is medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE test have been met. Therefore, we decided that the Plan has to pre-approve 
a transthoracic echocardiography (TTE) test.   
 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the chest x-ray provided. 
 
You asked the Plan to pay for the chest x-ray interpretation. You say that this claim should be paid. The Plan 
denied your request. The Plan says that another physician in the same medical group billed for a Column 1 
code, meaning that this Column 2 code is not payable without a modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that NCCI Procedure-to-Procedure (PTP) edits are 
based on services provided by the same physician to the same beneficiary on the same date of service. 
 
In this case, the Column 1 code referenced in this case was provided by a different physician. As such, the 
application of the PTP edit is not correct and there is no need for a modifier. The record supports that this 
interpretation was distinct from the other physician's services. Therefore, we decided that the Plan has to pay 
for the interpretation of the chest x-ray provided.  
 
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 a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you need to build the strength back in your leg. 
The Plan denied your request. The Plan says there are no daily skilled needs. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, you 
received oral medications, had stable vital signs, and were treated for pain with effect. You had a wound vac 
applied to your wound. There are identifiable skilled nursing service needs. Regarding rehab services, you are 
at a standby assist to contact guard assist level with bed mobility and transfers. You require varying assist with 
activities of daily living. There are no identifiable skilled therapy service needs. Although there are identifiable 
skilled nursing needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on June 29, 2020. 
 
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 procedure code 64999 should not be billed as anesthesia. 
 
The Plan must follow Medicare rules. The rules say that CPT codes describing anesthesia services (00100-
01999) or services that are bundled into anesthesia should not be reported in addition to the surgical or medical 
procedure. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 64999. This code 
should not be billed by an anesthesia practitioner and is not covered as anesthesia. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services rendered on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be rendered 
by an OON provider. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that you never received a list of 
dentists that you can go to. You also say that you chose this dentist, and would like to be seen by them because 
their office is close to you. The Plan denied your request. The Plan says this service is requested to be 
performed by an OON provider. The Plan also says that services are only covered by your plan for in network 
dentists. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) to be rendered by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveservices from a Licensed Marriage and Family Therapist (LMFT).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the provider is not covered.The Plan must follow Medicare rules. The rules say that a Licensed Marriage Family Therapist (LMFT) is not eligible to participate in Medicare. We looked at the file and Medicare rules. The requested provider is a Licensed Marriage Family Therapist. This provider type is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approveservices from a Licensed Marriage and Family Therapist (LMFT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa. 
 
You asked the Plan to pre-approve Vascepa. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa.  
 
Benefits for Vascepa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a 
knee replacement. Medical problems are stable. There are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. Youi do 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 you will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), surgical placement 
of implant body: endosteal implant (D6010), bone replacement graft for ridge preservation (D7953), fixed 
partial denture sectioning (D9120), extraction (D7210), and inhalation of nitrous oxide/analgesia (D9230) 
provided on July 6, 2020 by an OON provider. 
 
You asked the Plan to pay for the guided tissue regeneration, endosteal implant, bone replacement graft, fixed 
partial denture sectioning, extraction, and inhalation of nitrous oxide/analgesia. You say that you were referred 
to this treating oral surgeon, and were not aware that they were not in-network with your plan. The Plan denied 
your request. The Plan says the guided tissue regeneration, endosteal implant, bone replacement graft, and 
fixed partial denture sectioning are not covered benefits. The Plan also says that because this dentist is OON, 
the Plan pays according to a maximum allowable fee schedule and you are responsible for all of the fees in 
excess of this amount from the billed amount for the extraction and inhalation of nitrous oxide/analgesia. 
 
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, guided tissue regeneration, endosteal 
implant, bone replacement graft, and fixed partial denture sectioning are not among those covered under this 
benefit. You will also be responsible for the difference between the billed amount and the allowed amount for 
covered services that are received OON. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4266), surgical placement of implant body: endosteal implant (D6010), bone 
replacement graft for ridge preservation (D7953), fixed partial denture sectioning (D9120), extraction (D7210), 
and inhalation of nitrous oxide/analgesia (D9230) provided on July 6, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection services. 
 
You asked the Plan to pre-approve injection services. 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 injection services are only covered for certain 
indications. 
 
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 injection services. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have chronic neck pain. The documentation shows that you had sustained pain 
relief from previous injections. The exact degree and duration of pain relief is not documented well. Intra-
articular injections do not strongly predict response to radiofrequency ablation therapy, rather you would need 
to do diagnostic medial branch blocks. Therefore, at this point, the request is considered 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 injection services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve injection services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the sacroiliac joint injections (G0260) provided on February 
28, 2020. 
 
You asked the Plan to pay for the sacroiliac joint injections. You say that you would like reconsideration 
because authorization is not required for a CPT code which is essentially the same. The Plan denied your 
request. The Plan says CPT code G0260 requires authorization which was not obtained. 
 
Medicare rules say that plans may require enrollees to obtain authorization before receiving services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the sacroiliac joint injections (G0260) provided on 
February 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medial branch block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are radicular symptoms present. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the request is for L3, L4, and L5 medial branch blocks. The medical records describe the enrollee's pain 
as located in the lower lumbar region with bilateral radiation to the lower extremities to the posterior thighs and 
calves with the right greater than the left. The pain is exacerbated by bending and sitting and is further 
described as extending to around the ankle. The enrollee has lumbar radiculopathy. 
 
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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a medial branch block for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for portable X-Ray. You say that your services are treated as emergency care and 
your company is not allowed to access patient demographics ahead of time, which make obtaining prior 
authorization nearly impossible. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 5, 2020 
by an out of network (OON) provider.
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 
services are not medically necessary. Our physician reviewer found the submitted records show that you had a 
fall on November 7, 2020 and had a lumbar fracture. You are receiving home health care services for back 
pain. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by 
multiple therapies and an intensive rehab program in an IRF. There is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.