Persius/hicric huggingface dataset:
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 appealing the denial. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 that based on the limited medical records provided there is no documentation that 
daily skilled services are required. There is no documentation that you require the services on an inpatient 
basis, only in a skilled nursing facility setting. Records do not support that services in the home with home 
health care or in a long-term care facility on a part time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and don't think that you would receive 
the care you need at a skilled nursing facility. You are only walking 20-30 feet with assistance and don't have 
an appetite. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87640, 87641, 87653, 87798 
billed for date of service September 7, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87640, 87641, 87653, 87798. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says payment for codes 87150, 
87481, 87640, 87641, 87653, 87798 is bundled into payment for codes 87500 and/or 87801. 
 
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 87150, 
87481, 87640, 87641, 87653, 87798 are column II codes to column I codes 87500 and/or 87801. 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 codes 
87150, 87481, 87640, 87641, 87653, 87798 billed for date of service September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 75741-26-XS-RT billed for date of service September 
11, 2021. 
 
You asked the Plan to pay for code 75741-26-XS-RT. You say that this code is separately payable. The Plan 
denied your request. The Plan says this code is not separately payable. 
 The Plan follows Medicare rules. Medicare rules say that the XS modifier is used to report a service that is 
distinct because it was performed on a separate organ/ structure. Modifier XS should only be used for surgical 
procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different 
anatomic sites, arent ordinarily performed or encountered on the same day, and cant be described by a more 
specific anatomic modifier.  
 
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 code 75741-26-XS-RT. Our reviewer says 
that this code is not separately payable based on the records. Our physician reviewer found the procedure report 
describes bilateral pulmonary angiogram performed with aspiration thrombectomy.  In this case, the 
angiography would be inclusive to the intervention performed, as (Per NCCI Policy) "Open and percutaneous 
interventional vascular procedures include operative angiograms and/or venograms". Therefore, this pulmonary 
angiography cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 75741-26-XS-RT have not been met. Therefore, we decided that the Plan 
does not have to pay for code 75741-26-XS-RT billed for date of service September 11, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis 0.3MG/0.05ML syringe (CPT code J2778). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 medication. Our physician reviewer 
found the documentation does not support that Avastin would likely be less effective, and/or would likely have 
adverse effects for the enrollee 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lucentis 0.3MG/0.05ML syringe (CPT code J2778).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), a manual swingaway 
(E1028), a center mount power leg rest (E1012), a skin protection and positioning seat cushion (E2624), a toe 
loop (E0952), a wheelchair tray (E0950), a power seat elevation system (E2300) and a cell-phone holder 
(K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller, a manual swingaway, a center mount power leg 
rest, a skin protection and positioning seat cushion, a toe loop, a wheelchair tray, a power seat elevation system 
and a cell-phone holder. You say that the requested items are a medical necessity for the enrollee. The Plan 
denied your request. The Plan says the requested items are not medically necessary or serve no medical 
purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that a power seat elevation feature (E2300) and power standing 
feature (E2301) are non-covered because they are not primarily medical in nature, and that for equipment to be 
covered, it must primarily serve a medical purpose. 
 
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 expandable controller, a manual 
swingaway, a center mount power leg rest and a skin protection and positioning seat cushion. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation does not indicate that the enrollee has any pressure injuries that would 
necessitate a special cushion. There is no medical necessity for the swingaway hardware. The documentation 
doesn't support that the enrollee has any edema that would require elevating leg rests. The requested electrical 
accessories are not medically necessary as the enrollee does have use of the upper extremity and can operate 
and control the power options using the switches that are included in the basic wheelchair. 
 
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 expandable controller, a manual swingaway, a center mount power leg rest 
and a skin protection and positioning seat cushion have not been met. A toe loop, a wheelchair tray, a power 
seat elevation system and a cell-phone holder do not primarily serve a medical purpose. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller (E2377), a manual swingaway (E1028), a 
center mount power leg rest (E1012), a skin protection and positioning seat cushion (E2624), a toe loop 
(E0952), a wheelchair tray (E0950), a power seat elevation system (E2300) and a cell-phone holder (K0108) 
for a power wheelchair.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for a stroke and encephalopathy. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are needed for the enrollee to regain 
maximum function. The Plan denied your request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve a microprocessor knee. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan follows Medicare rules. Medicare rules say that microprocessor knees 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 a microprocessor knee. Our reviewer 
says that the documentation does not support that the requested microprocessor knee is medically reasonable or 
necessary. Our physician reviewer found you have been evaluated as a K3 functional level and is expected to 
be a K3 functional level. Your current knee is Blatchford KX046 four bar polycentric hydraulic. The 
documentation is not clear that your needs cannot be met with a mechanical knee with stance flexion. 
Therefore, you do not meet criteria for the requested item. 
 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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for elective knee replacement. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 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 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 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 you are living at home with increased weakness and confusion. The records show 
you are medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in constant pain. The 
Plan denied your request. The Plan says there is no documentation of a plan for a different approach. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical 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 the requested services. Our physician 
reviewer found that the enrollee has chronic low back pain, lumbar spondylosis, lumbar degenerative disc 
disease, and lumbar radiculopathy. He received a bilateral transforaminal ESIs at L4-L5 levels on December 4, 
2022. The enrollee experienced 70% relief of pain for two weeks. A second bilateral transforaminal ESIs at the 
L4 and L5 levels was recommended. There is no documentation that a different approach, level, and/or 
medication is planned on being used. The review has determined that the records show that the enrollee does 
not meet the criteria for repeat injections. 
 
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 a repeat epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology visit (93289, 99215, 93283, 93000) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the cardiology visit. You say that the out-of-network provider performed the 
surgery so they should do the follow up. The Plan denied your request. The Plan says there are in-network 
cardiologists that can provide the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
cardiology visit (93289, 99215, 93283, 93000) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory/pathology services (88312, 88305) provided on 
July 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory/pathology services. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan says out-of-network care is covered only 
in certain limited circumstances. The services at issue were not urgent or emergent, pre-approved or referred by 
a network provider. 
 
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 referred and/or 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/pathology services 
(88312, 88305) provided on July 28, 2022, by an out-of-network (OON) provider.