Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you still have a lot of pain in your knee 
and feel more visits are needed to strengthen the muscles for better control improved movement. The Plan 
denied your request. The Plan says the documentation notes an ability to perform a home exercise program, and 
does not support any objective improvement despite 20 visits for your condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. Our reviewer found that 
you have had prior therapy and the documentation does not reveal that you require the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. Our physician reviewer also found that you can continue with a home exercise 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (A4220) provided on January 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A4220 has a status indicator of P on the Physician Fee Schedule. This means that code 
A4220 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services (A4220) 
provided on January 20, 2022.
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 the LTACH is medically necessary, and 
you are ready to go the LTACH. The Plan denied your request. The Plan says authorization denied because the 
LTACH is not medically necessary, and you are receiving appropriate care at the current facility and are not 
stable for transfer. 
 
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 there is no documentation provided indicating medical necessity for LTACH 
services. You are receiving appropriate care at the present acute care hospital. You do not require services at 
the LTACH that are not available at the acute care hospital where you are currently receiving 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee is ill and cannot go back home. 
You say that the enrollee has been in the hospital for too long and there is no reason for her to be there 
anymore. You say that the enrollee needs to be in a step-down unit before returning home. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can 
receive the care needed in another setting.  
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 the SNF services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee 
is consistently ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal 
supervision.  The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a 
lower 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
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 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 health plan. The health plan has approved ongoing care 
in the current acute care 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the patient is in pain and would like the 
requested service. The Plan denied your request. The Plan says that records show the enrollee does not have an 
80% improvement in back pain with the first MBB injections. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The enrollee only 
had a 50% improvement in her back pain with the first medial branch block injections. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (0037U) provided on December 
22, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the testing services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the genetic testing services (0037U) provided on 
December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that you confirmed with the in-
network provider that they do not have the lymphoedema pump with gradient pressure available, just the one 
without the gradient pressure. The Plan denied your request. The Plan says medically necessary care is 
available in-network for a pneumatic compression device without gradient pressure and the device with 
gradient pressure is not necessary.  
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 5, 2021, to April 
9, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 193 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee presented with low saturation, 
cough and shortness of breath. The emergency department exam documented a temperature of 98.9 degrees, 
pulse 98, respiratory rate 18, blood pressure 149/66 and pulse oxygen saturation (SpO2) 90% on room air. The 
enrollee was described as in no acute distress, lungs revealed wheezing, rhonchi, and rales, accessory muscle 
use and respiratory distress present, and no focal neurologic deficits. She was diagnosed with pneumonia and 
admitted for further care. Treatment included IV fluids, IV antibiotics and nebulized bronchodilator therapy. 
While it was acknowledged that the records include a physician-documented diagnosis of sepsis, and that 
Systemic Inflammatory Response Syndrome (SIRS) signs were present along with an elevated lactic acid, the 
clinical findings in the record did not sufficiently support the diagnosis of sepsis based on Sepsis 3 criteria. The 
review has determined that the medical records did not support the billing of sepsis, unspecified organism 
(A41.9). 
 
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 care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from April 5, 2021, to April 9, 2021, as 
billed with Diagnosis Related Group (DRG) 871.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (64555) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that approval of these services would accomplish 
getting the enrollee off the narcotic medications and lead to her being able to drive and accomplish daily 
activities. The Plan denied your request. The Plan says that records do not show that the underlying cause of 
the enrollee's shoulder pain has been investigated or that it is associated with weakness following a stroke, 
inflammation of the spinal cord at C5/C6 or adhesive capsulitis.  
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no evidence 
that this is helpful in chronic musculoskeletal pain, primary osteoarthritis, subacromial impingement, spinal 
cord injury or post-stroke in individuals with arm weakness. The use of this device here would be 
experimental/ investigational. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (64555) for 
the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for an additional unit of a wheelchair accessory (E1028) repair provided to 
the enrollee on May 28, 2021. 
 
You asked the Plan to pay for the services. You say that this is the first time you are billing these codes. The 
Plan denied your request. The Plan says that this service exceeds the recommended frequency per Medicare 
guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not substantiated their denial in this case. 
 
The Plan has denied this claim for an additional unit of E1028, stating that this service exceeds the 
recommended frequency per Medicare guidelines. The plan cites a rule about the reasonable useful lifetime 
period for durable medical equipment (DME). This denial rule is not valid, as the item is being repaired, not 
replaced. It is also not valid, as the plan paid for one unit in 2019, and 5 units in 2021. There is no specific 
reason given for why this additional unit in 2021 is not reasonable at this time. Therefore, we decided that the 
Plan has to pay for an additional unit of a wheelchair accessory (E1028) repair provided to the enrollee on May 
28, 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The 
Plan denied your request. The Plan says 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 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 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 she is currently 
receiving 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 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 lab services provided on April 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 9, 2021.
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 admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found you received oral medications, had stable 
vital signs and was treated for pain. You do not require skilled nursing or therapy services on a daily basis. You 
do not meet severity of illness or intensity of service criteria for 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.