Persius/hicric huggingface dataset:
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 therapy in the IRF setting would be best for this 
enrollee. The Plan denied your request. The Plan says the enrollee does not appear to need a require physician 
with specialized rehab training or a coordinated interdisciplinary team. 
 
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 
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 non-surgical management of fractures of fibula and 4th and 5th metatarsals after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the patient has a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total disc arthroplasty services. 
 
You asked the Plan to pre-approve total disc arthroplasty services. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says under Medicare guidelines, this request is considered 
investigational and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cervical disc replacement is considered 
investigational when there has been a previous fusion at another level. 
 
We looked at the file and Medicare rules. In this case, the enrollee has received a previous fusion surgery at 
another level. Based on this information, we decided that Medicare rules for coverage of total disc arthroplasty 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve total disc 
arthroplasty services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME (CPT code(s): A4253 and A4256) provided from 
August 2, 2021, through October 31, 2021. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation received did not contain the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the DME have been met. The provider 
did not submit medical documentation to verify if the services were supported. Therefore, we decided that the 
Plan does not have to pay for the DME (CPT code(s): A4253 and A4256) provided from August 2, 2021, 
through October 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot get back to their baseline if they 
do not get help. You state the enrollee needs extra care with physical therapy and occupational therapy at this 
time. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. 
The Plan states the enrollee's records do not show that they need either daily skilled nursing care or therapy.  
 
 The services the enrollee requires, intermittent therapy or a restorative program, and help from their family 
with their finances, can safely be received at a different setting, for example, home with home health, in 
residential care, or home with close follow-up with the enrollee's doctor. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is 
ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. The enrollee is medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The 
enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The 
enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's 
physical function is at or near their baseline and they can receive services at a lower level of care. Admission to 
a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 87150) provided on July 
29, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 87150 remains 
not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient 
when the specimen was obtained. The submitted claim for indicates the laboratory specimen was obtained in a 
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11. Also, the laboratory results indicate the specimen was 
collected on July 29, 2021, and received by the lab on August 2, 2021. In addition, the medical records 
submitted indicate that a gastrointestinal pathogen, multiplex reverse transcription and multiplex amplified 
probe technique, multiple types of subtypes, 22 targets test was performed. CPT code 87150, culture typing, 
amplified technique was billed. However, there is a more appropriate CPT code 0097U that should be used to 
billed for the service provided. Therefore, the billed code, units and place of service cannot be verified. 
Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 87150) provided 
on July 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for secondary percutaneous transluminal thrombectomy (eg, 
nonprimary mechanical, snare basket, suction technique), noncoronary, non-intracranial, arterial or arterial 
bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, 
provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy 
(List separately in addition to code for primary procedure) (CPT code 37186-59) provided on November 16, 
2021. You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by 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 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 service. Our reviewer found the review has determined 
that the service is not supported by the medical records provided. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, 
suction technique), noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic 
guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another 
percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to code for 
primary procedure) (CPT code 37186-59) provided on November 16, 2021.
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 is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the patient was admitted for a stroke and was transferred to a skilled nursing 
facility on March 14, 2022. Medical problems are stable. 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. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In 
conclusion, 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 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 injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar 
or sacral; second level (CPT code 64494) provided on October 6, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. CPT code 64494 exceeds the 
allowable UOS of 1 for the same date of service per the MAI indicator of "2" and was not billed correctly per 
the bilateral surgery indicator of "1" guidance; we find that Medicare rule for payment of this claim has not 
been met. If the provider determines that a billing error occurred during the initial submission of the denied 
claim, the plan will accept a submission of a corrected claim to consider services for payment. Therefore, we 
decided that the Plan does not have to pay for the injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar 
or sacral; second level (CPT code 64494) provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 21, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on September 21, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on August 13, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee sleeves (CPT code L2397) and the knee orthosis 
(CPT code L1851) provided on October 11, 2021. 
 
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the documentation indicates services are not 
necessary for treatment of the enrollees condition. 
 
 
 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 orthoses and sleeves. Our physician 
reviewer found the enrollee has not had recent surgery or a recent injury. The documentation doesnt support 
that the joint is unstable or that there is joint laxity. The requested knee orthoses are 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 the orthoses and sleeves have not been met. Therefore, we decided that the Plan 
does not have to pay for the knee sleeves (CPT code L2397) and the knee orthosis (CPT code L1851) provided 
on October 11, 2021.
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 need this level of care due to your health that is 
deteriorating. The Plan denied your request. The Plan says you do not meet Medicare criteria for IRF 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 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 
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 ischemia of the bowel, colectomy, aspiration pneumonia, and respiratory failure. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the patient has a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient meets IRF criteria. The Plan denied your 
request. The Plan says IRF care 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 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 
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 is living at home with a history of diabetes, spinal cord injury, paraparesis, lower extremity 
weakness. He has been receiving care as an outpatient for pressure ulcers of the lower extremities. His other 
medical problems are stable. 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. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (aducanumab) injections. 
 
You asked the Plan to pre-approve the Aduhelm treatment. You say that this treatment is medically necessary. 
The Plan denied your request. The Plan says the documentation does not have sufficient evidence to show that 
Adulhelm is reasonable and necessary in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aduhelm treatment. Our reviewer 
says that the requested treatment is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that Aduhelm is reasonably expected to be safe 
and effective for the enrollee in this case. The case file does not contain documentation of a Mini-Mental State 
Examination (MMSE) or other measures of cognition. The MRI imaging supports the presence of 
cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. It has not been 
shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate 
alternatives for this enrollee. 
 
 
 
 
 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 Aduhelm treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Aduhelm (aducanumab) injections.