Persius/hicric huggingface dataset:
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 would not be able to go home and move around, 
or fully take care of yourself. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component of anesthesia (99153) provided on 
April 14, 2022. 
 
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this code is not separately paid when furnished to a hospital inpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a 
practice expense (PE) only code and that practice expenses are not payable to the physician for services 
provided in the facility setting. 
 
We looked at the file and Medicare rules. We find that payment for CPT code 99153 is not supported. 
Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility 
setting. Therefore, we decided that the Plan does not have to pay for the technical component of anesthesia 
(99153) provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve ablation at 
L5-S1. 
 
You asked the Plan to pre-approve Intracept intraosseous basivertebral nerve ablation at L5-S1. You say that 
this procedure fills a treatment gap for those patients that do not receive adequate relief from traditional 
conservative methods and don't have instability to indicate fusion is the appropriate treatment. You say that the 
enrollee has tried conservative treatment without relief. You say that the Food and Drug Administration (FDA) 
clearance of this procedure means that it is safe and effective. The Plan denied your request. The Plan says the 
clinical value and effectiveness of the Intracept procedure in the setting of vertebrogenic low back pain have 
not been demonstrated in the peer-reviewed literature. The Plan says that more research is needed to show 
safety and efficacy of the procedure. 
 
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 Intracept intraosseous basivertebral 
nerve ablation at L5-S1. Our reviewer says that Intracept intraosseous basivertebral nerve ablation at L5-S1 is 
not considered medically reasonable and necessary in this case. Our physician reviewer found there are multiple plausible pathologic sources of significant pain generation. The pain across the low back, the noted 
pain-aggravating factors (exercise, standing for 5 minutes, walking for 3 minutes, and bending forward), pain-
relieving factors (lying down and sitting), along with the intact neurologic exam are all non-specific to any 
pathologic entities. Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept intraosseous basivertebral nerve ablation at L5-S1 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve 
ablation at L5-S1.
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 had a triple bypass, and you are appealing the 
denial of IRF services. 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for intravascular ultrasound and angiography (procedure codes 37253, 
75710) provided to the enrollee on March 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes remain not supported. 
 
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, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the lower extremity angiogram 
was documented and was the first angiographic procedure to document abnormal lower extremity arteries. No 
pre-op exam had been done. Thus, this procedure would not be part of the approved CPT 37229. The denial for 
endovascular ultrasound x3 - CPT 37252 stated the procedures were not documented in the report. However, 
there is adequate documentation of three vessels that had been evaluated with ultrasound; thus, this code x3 is 
supported in the records. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
intravascular ultrasound and angiography (procedure codes 37253, 75710) provided to the enrollee on March 
28, 2022.  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF due to their 
physical and occupational deficits along with their co morbidities. This would give them a chance to optimize 
their mobility and regain the ability to perform activities of daily living. The Plan denied your request. The 
Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a SNF. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 documentation does not reveal that the enrollee requires or can tolerate this 
therapy on an intensive IRF level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on January 26, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says a prior 
authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the surgery services provided on January 26, 2021, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that are not 
available at the health care setting being offered by the Health 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 the 
LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH 
services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 11, 2021. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the testing exceeds the enrollee's medical needs. 
 
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. The file shows that a urinary tract infection panel was provided. The 
medical records do not show that the enrollee was being treated for a urinary tract infection. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on November 11, 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 you are appealing with supporting records. 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 daily skilled services are not required. There is no documentation that the enrollee 
requires services on an inpatient basis, only in a skilled nursing facility setting. Records support that services in 
the home with home health care or in a long-term care facility on a part time basis are more 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee-skin system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a microprocessor knee is not medically reasonable and necessary as 
defined by Medicare criteria. 
 
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 system. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records document he requires a power wheelchair and walker in his home and 
a rollator outside the home; this is not consistent with a K3 ambulatory level. Also, given his other diagnoses of 
chronic restrictive lung disease on supplemental oxygen, myotonic dystrophy type 1, obesity and chronic back 
pain, the totality of the provided records do not support that the enrollee is a K3 level ambulator. The totality of 
the provided records does not support this request as being 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a microprocessor knee-skin system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on May 5, 2022, to May 6, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the enrollee 
must use network providers unless prior authorization is granted. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the surgery services provided on May 5, 2022, to May 6, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block (64454LT) provided on April 8, 
2022. 
 
You asked the Plan to pay for the injection. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the service was 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 pay for the injection. Our reviewer says that the 
genicular nerve block is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of genicular nerve blocks and radiofreqeuncy ablation (RFA) in osteoarthritis of the 
knee is still be evaluated. The reviewer found that this is considered experimental/investigational at this time. 
Therefore, the requested genicular nerve blocks are medically not 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the genicular nerve block (64454LT) provided on April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient care to be provided at the in-network benefit 
level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an in-network exception. You say that you have been treated by this 
provider previously. You say that they already have an established exemption for you. You also say that you 
feel you should not have to find a new provider at your age. The Plan denied your request. The Plan says a 
network exception cannot be made when there are in-network providers available. 
 
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 confirmed there are 
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 at the in-network benefit level. Therefore, we decided that 
the Plan does not have to pre-approve outpatient care to be provided at the in-network benefit level by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve second stage of sacral neuromodulation (CPT code 
64590). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says an additional stimulator is not 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 the service. Our physician reviewer found the medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 
The records indicate that urodynamics demonstrate stress incontinence rather than urge incontinence. 
Neuromodulation is indicated for overactive bladder/urge incontinence and not stress incontinence. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve second stage of sacral neuromodulation (CPT code 64590).