Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical necessity 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 daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not require skilled 
nursing services. The enrollee does require skilled therapy services. However, the available documentation 
does not support that it is medically reasonable and necessary to provide skilled services on a "daily basis" on 
an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level of facet joint radiofrequency ablation 
(RFA). 
 
You asked the Plan to pre-approve a third level of facet joint RFA. You say that all three levels requested of 
facet joint RFA are medically necessary. The Plan denied your request. The Plan says it has approved two 
levels of facet joint RFA, but the third level does not meet medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint radiofrequency ablation, one to two levels, 
either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level 
procedure bilaterally may be considered under unique circumstances and with sufficient documentation of 
medical necessity 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a third level of facet joint RFA. Our 
reviewer says that a third level facet joint RFA is not medically necessary or reasonable in this case. We looked 
at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of a third level of facet joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a third level of facet joint radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you believe this surgery is medically 
necessary. The Plan denied your request. The Plan says this surgery is not medically necessary. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is considered experimental and more research is needed to 
determine its efficacy. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trilogy ventilator. 
 
You asked the Plan to pre-approve a Trilogy ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a Trilogy ventilator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that supports 
continued coverage for the Trilogy ventilator at issue in this case as defined by health plan and Medicare 
criteria. Criteria for continued coverage requires 70% compliance with use of the ventilator for 4 hours per 
night. The latest compliance data for you documents 61.1% compliance with use. You explained that your non-
compliance was due to a bad tooth, and that the air from the machine was hurting the tooth. You stated that you 
had no way to get to the dentist at that time to have the issue taken care of. Records do not document that the 
dental issue has since been remedied to allow you to resume compliant use to the ventilator. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Trilogy ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Trilogy ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026) and manual therapy techniques 
(97140) provided by an acupuncturist on November 5, 2020. 
 
You asked the Plan to pay for infrared therapy (97026) and manual therapy techniques (97140). You say that 
medical records pertaining to the services are enclosed and payment should be arranged. The Plan denied your 
request. The Plan says infrared therapy (97026) is not a covered benefit and manual therapy techniques (97140) 
was not billed with an appropriate therapy modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently 
attempt to enroll in Medicare but are not eligible to do so. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy (97026) and manual therapy techniques (97140) have not been met. Specifically, 
services provided by an acupuncturist are not covered.  
 
  
Therefore, we decided that the Plan does not have to pay for infrared therapy (97026) and manual therapy 
techniques (97140) provided by an acupuncturist on November 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI scan of the lumbar spine. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
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 scan of the lumbar spine. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of an X-ray or conservative measures for low-back pain. 
 
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 scan 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) scan of the lumbar spine (72148).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total of 4 units of oral function therapy (92526) provided 
on October 29, 2021, and November 3, 2021. 
 You asked the Plan to pay for a total of 4 units of code 92526. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92526 is 1. The MAI value for this code is 2. You billed a total of 4 units 
of this code, 2 units on each date of service, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of a total of 4 units of code 92526 have not been met. Therefore, we decided that 
the Plan does not have to pay for a total of 4 units of oral function therapy (92526) provided on October 29, 
2021, and November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says services 
that are not medically necessary are not covered. 
 
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 requested services. Our physician 
reviewer found that interspinous stabilization devices are experimental. More research is needed to show safety 
and efficacy. Therefore, the requested services are not considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus Test Strips. 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus Test Strips. You say that you would like 
reconsideration because you already use this brand and would prefer to continue with it. The Plan denied your 
request. The Plan says you do not meet exception criteria for coverage of a non-preferred brand of testing 
supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 Accu-Chek Aviva Plus Test Strips. 
have been met. Specifically, the documentation submitted does not include any clinical information to verify 
that you have tried and failed the Plan's preferred brands or that the Plan's preferred brands would be 
contraindicated for you. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva 
Plus Test Strips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You did not provide an argument with your appeal request. The 
Plan denied your request. The Plan says The patient had a PET scan in May of 2021 that did not show any 
worrisome findings and the lung nodule can be followed with chest computed tomography (CT) scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our 
reviewer says that a PET scan is not medically necessary at this time. Our physician reviewer found both lung 
nodule and axillary nodes can be appropriately followed with CT scan instead.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services provided on August 13, 2021. 
 
You asked the Plan to pre-approve the laboratory services. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 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 laboratory services provided on 
August 13, 2021, have been met. In this case, there are no records submitted from the ordering physician 
specifying the medical necessity of the testing services provided. Therefore, we decided that the Plan does not 
have to pre-approve the laboratory services provided on August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 5, 2021, to 
August 23, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that your necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 5, 2021, to August 23, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says the enrollee 
will not require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient services. Our physician 
reviewer found that the enrollee has been approved for a transforaminal lumbar interbody fusion. She is 
medically stable and has been provided medical clearance for this procedure. There is no documentation to 
support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that 
the enrollee's necessary hospital care will span two midnights. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an inpatient hospital admission.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 6 home health PT visits. You say that you had a knee replacement. You said 
that you not drive and are homebound and not ready to go to an outpatient facility for PT. You also said that 
you do not have transportation to and from the facility. The Plan denied your request. The Plan says the records 
do not support the need for a skilled physical therapist to make more home visits at this time. You began receiving home PT on March 17, 2022, following knee replacement. Ample time has been provided to establish 
a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 6 home health PT visits. Our reviewer 
says that the 6 requested home health PT visits are not medically necessary. Our physician reviewer found the 
documentation does not support that an additional 6 home health PT visits are medically reasonable and 
necessary for you. You have received therapy instructions, including safety measures, an emergency plan, and 
fall precautions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 home health PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 home health physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity 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 complexity of the enrollee's nursing, medical, and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee 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 the enrollee 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for LTACH care 
have not been met. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where the enrollee is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the Plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.