Persius/hicric huggingface dataset:
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 has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found it would be expected that you would require close medical supervision by a rehabilitation physician and 
nursing on an inpatient basis during rehabilitation. Evaluating physical and occupational therapists document 
that you would tolerate 3hrs of therapy per day and the preadmission screening shows that you would benefit 
significantly. Thus, IRF criteria have been met and is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3010 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code J3010. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 3.  
 
In this case, the MUE for CPT code J3010 is 100. The MAI value for this code is 3. You billed 1000 units of 
this code total, exceeding the MUE. The Plan notes that they have previously paid the allowable 100 units. 
Based on this information, we decided that Medicare rules for coverage of procedure code J3010 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code J3010 billed for date of 
service March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair. 
 
You asked the Plan to pre-approve a heavy-duty power wheelchair. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the documentation does not support why you require this 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty power wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF to gain strength and be able 
to return home. The Plan denied your request. The Plan says you do not meet the criteria for SNF care and can 
be treated in a lower level of care. 
 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 although you have functional impairments and skilled nursing needs, you require 
close medical supervision and intense therapy. Close medical supervision and intense therapy is not available 
in a skilled nursing facility; therefore, SNF services are not medically necessary from a practical standpoint. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 clinical documentation shows that you do have active comorbidities however, 
evaluating therapists document poor tolerance in evaluations and there is no specific recommendation documented that you would be able to tolerate 3hrs of therapy or intense therapy. Thus, IRF criteria have not 
been met. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. The Plan denied your request. The Plan says the requested 
therapy services are not medically necessary. 
 
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 therapy 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 that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing visits (G0299 x6). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's records do not support the need for a skilled nurse to make more visits. 
 
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 the services. Our physician reviewer 
found clinical documentation shows that the enrollee was receiving wound care per home health nursing, but 
physician notes state that wounds have healed and to only continue wrapping; thus, six (6) additional home 
health skilled nursing visits are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home health skilled nursing visits (G0299 x6).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 documentation does not support necessity for admission to an IRF as there is no 
medical complexity or nursing needs. While the enrollee may benefit from continued physical and occupational therapy, the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 documentation does not support necessity for admission to an IRF as there is no 
medical complexity or nursing needs. While you may benefit from continued physical and occupational therapy, your rehabilitation needs can be provided in a lower intensity and alternate setting such as in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral 
or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess 
stenosis]), single vertebral segment; lumbar (CPT code 63047), arthrodesis, posterior or posterolateral 
technique, single interspace; lumbar (with lateral transverse technique, when performed) (22612) and posterior 
non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial 
transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (22840). 
 
You asked the Plan to pre-approve the surgical services. You say that your doctor told you that the pain could 
only be relieved through surgical procedure. The Plan denied your request. The Plan says your request is not 
medically necessary because your records show you do not have spinal instability, symptoms not responsive to 
one year of non-operative treatment, or symptomatic compression of neural elements. 
 
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 surgical services. Our physician 
reviewer found the records show that you only have had back pain for eight (8) weeks and have not had 
adequate conservative measures to include a recent trial of physical therapy (PT) for lower back pain (LBP). 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 
decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single 
vertebral segment; lumbar (CPT code 63047), arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (with lateral transverse technique, when performed) (22612) and posterior non-segmental 
instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular 
screw fixation, sublaminar wiring at C1, facet screw fixation) (22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that in 
this case, there is no documentation of the enrollee's inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care. There is also 
no documentation of the degree and length of pain relief from prior epidural steroid injections. The review has 
determined that the requested epidural steroid injection does not meet the Medicare LCD coverage criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the knee x-ray (73562) and ankle x-ray 
(73610) provided on April 25, 2022. 
 
You asked the Plan to reduce the cost share for the knee and ankle x-rays. You say that you previously paid 
$87.78 for these x-rays to be interpreted, and are now being billed $737 which is listed as the cost of the 
insurance deductible, and not the cost of the x-rays. You also say that according to the Plan information that 
was sent to you in January 2022, the copay for the x-rays is $30.00. The Plan denied your request. The Plan 
says the amount charged applied correctly toward the deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to x-rays.  
 
The item or service you asked the Plan to reduce the cost share for falls within the benefit category for 
Outpatient Diagnostic Tests. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is $1,000 deductible which applies to x-rays. This cost sharing is a contractual obligation that had not 
been met at the time the x-rays were received on April 25, 2022. Therefore, we decided that the Plan does not 
have to reduce the cost share for the knee x-ray (73562) and ankle x-ray (73610) provided on April 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 29881-RT billed for date of service February 17, 2022. 
 
You asked the Plan to pay for code 29881-RT. You say that the surgeon was paid for this code, so your facility 
should be paid as well. The Plan denied your request. The Plan says code 29881-RT is not supported by the 
medical record. The operative report supports a different code for the arthroscopy of the right knee with medial 
and lateral meniscectomy. Both compartments underwent partial medial and lateral meniscectomy. 
 
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 code 29881-RT is arthroscopy, knee, surgical; with 
meniscectomy [medial OR lateral, including meniscal shaving). 
 
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 code 29881-RT. Our reviewer says that code 29881-RT is 
not supported in the medical record. Our reviewer found both the medial and lateral meniscectomy were 
performed and there is a more appropriate procedure code to represent that service. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 29881-RT have not been met. Therefore, we decided that the Plan does not 
have to pay for code 29881-RT billed for date of service February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PBRT (CPT code 77523). 
 
You asked the Plan to pre-approve the PBRT. You say that this treatment is approvable because the enrollee is 
enrolled in a clinical trial. The Plan denied your request. The Plan says the enrollee's records show that they are 
enrolled in an observational registry study, but not a true clinical trial. The Plan states PBRT is not a standard 
therapy for prostate cancer yet. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation 
therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
The most recent American Urological Association (AUA) guidelines state that PBRT offers no clinical 
advantage over other forms of definitive treatment. 
 
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 PBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PBRT (CPT code 77523).