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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's current needs cannot be 
met at a lower level of care. The Plan denied your request. The Plan says admission to LTACH was denied as 
not meeting criteria, is not medically necessary, and continued acute hospital stay was offered, until the 
enrollee could discharge to a lower level of care. 
 
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 enrollee with chronic obstructive pulmonary disease (COPD) and prior lobectomy 
on home oxygen was admitted to the acute care hospital with acute respiratory failure, COPD exacerbation, 
non-ST-elevation myocardial infarction, and pseudomonas bacteremia requiring vent support and antibiotics. 
Trach and percutaneous endoscopic gastrostomy feeding tube were placed.  
 The enrollee appears to be somewhat unstable and requires additional short-term acute care services that can 
safely be administered at the current facility until more stable and appropriate for transfer to a lower level of 
care. The enrollee does not require services at the LTACH that are not available at the current 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2022 billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 28, 2022 billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device. 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is unproven. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Food and Drug Administration (FDA) contraindications for the Vertiflex 
device include spinal instability, scoliosis, obesity, and osteoporosis, which have not been adequately addressed 
in the medical records. 
 
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 insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of long-term 
acute care hospital admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
in-patient acute care and does not require transfer to a long-term acute care hospital. 
 
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 enrollee was admitted to the acute care hospital with worsening sacral wound 
requiring antibiotics and wound care and complicated by osteomyelitis and sepsis. Recent notes describe the 
sepsis as resolved, requiring no more surgery, and still on intravenous antibiotics for the next week. The 
enrollee appears to be stable and improving and should only require short-term additional acute care services 
that can safely be administered at the current facility until more stable and appropriate for transfer to a lower 
level of care. The enrollee does not require services at the LTACH that are not already available at the current 
facility.  
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of LTACH 
admission as the enrollee will be discharging from hospital with a peripherally inserted central catheter, 
intravenous antibiotics and possible drain. The Plan denied your request. The Plan says there is no 
documentation that services cannot be provided in a less intensive setting. 
 
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 enrollee was admitted to the acute care hospital with acute kidney injury, septic 
shock, related to colitis and left hip abscess. They enrollee was treated with fluids, vasopressors, dialysis, 
incision and drainage, drain placement and antibiotics. Recent notes describe the enrollee with resolved 
leukocytosis, resolved sepsis, improving diarrhea and stable vitals with plans to transition to oral antibiotics.  
 
 The enrollee appears to be stable and improving and should only require short-term additional acute care 
services that can safely be administered at the current facility until more stable and appropriate for transfer to a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. 
 
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that 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 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 medically necessary. Our physician reviewer found the enrollee is 
medically stable and does not require services at the LTACH that are not available at the current setting. There 
are no services at the LTACH that are not available at the current setting. The LTACH services are not 
reasonable or medically necessary 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine without contrast (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you have pain in your lower back 
between spine discs L4 and LS and need this MRI done. The Plan denied your request. The Plan says you do 
not meet Medicare criteria. 
 
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 an MRI of the lumbar spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation of a trial of conservative measures to include physical therapy for low back pain. There are no 
red flags for lumbar MRI 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 an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine without contrast 
(72148).
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 enrollee meets all necessary criteria and will help 
further decline in physical abilities. The enrollee is ready, willing and able to take part in inpatient 
rehabilitation with the ultimate goal to walk again. The Plan denied your request. The Plan says the criteria has 
not been met for an inpatient rehabilitation facility 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee is currently at home with home care part time, has back pain from 
spinal stenosis and is wheelchair dependent. There are no acute medical problems and no recent 
hospitalizations. The enrollee is medically stable. There are no complex nursing or rehabilitation needs. While 
the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox for the enrollee. 
 
You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the Food and Drug Administration (FDA) and CMS nationally approved compendia 
do not support the use of OnabotulinumtoxinA for the diagnosis of gastroparesis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that Botox is 
not considered medically reasonable and necessary in this case. The enrollee has a diagnosis of gastroparesisis. 
The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox for the enrollee.
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 you are requesting SNF services. The Plan denied 
your request. The Plan says rules for SNF care have not been met. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interlaminar epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural injection. You say that the injections are necessary. The Plan 
denied your request. The Plan says the previous epidural injection provided on May 9, 2022, did not provide 
pain relief of 50% for 3 months and thus CMS criteria has not been met to cover another epidural injection. 
 
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 an epidural injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has tried physical therapy as well as NSAIDs and Opiates. Imaging 
shows L4-L5 disc bulge with moderate stenosis and L5-S1 disc protrusion. This request does not meet criteria 
based on both over-utilization as well as a lack of efficacy as the last injection only produced 10% pain relief 
for 4 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 an epidural injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interlaminar epidural steroid injection (62323).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would lack the ability to regain 
maximum function at a lower level of care. The enrollee would benefit from 3 hours of therapy required of 
acute rehabilitation. The Plan denied your request. The Plan says that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that clinical situation is complex, and the enrollee would require close 
medical monitoring on an inpatient basis. Evaluating therapists and PMR consult note all recommend that the 
enrollee have intense, multi-disciplinary rehabilitation and that the enrollee would tolerate and significantly 
benefit thus IRF criteria has been met and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services0 provided on November 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-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 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 had network providers 
available who could have provided 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 laboratory services0 provided on November 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service 
October 19, 2021. 
 
You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 32550. 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, we have confirmed that code 71045 
is a column II code to column I code CPT 32550. This claim has not been billed with an appropriate modifier 
to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service 
October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81161, 81286, 81413, 81414, 81442 and 
81479) provided on February 24, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary, and they were 
performed by an accredited laboratory. The Plan denied your request. The Plan says no documentation was 
provided to support these services as medically necessary and reported correctly. The provider selected for 
review is the one whose payment is at risk, and therefore this provider is responsible for submitting the 
necessary documentation. 
 
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 laboratory have been met. Specifically, 
no medical records or physician order were submitted to show that these services were medically necessary and 
reported correctly. Therefore, we decided that the Plan does not have to pay for laboratory services (81161, 
81286, 81413, 81414, 81442 and 81479) provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on March 17, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is no 
documentation provided to support how the test results will impact the treatment of the enrollee. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on March 17, 2021.