Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH. 
 
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 evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. Our reviewer also found that the enrollee can remain at 
the current ACH until such time no acute services are required. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat paravertebral facet joint radiofrequency ablation for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show an 80% improvement in pain from the medial branch 
blocks. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat thermal facet joint radiofrequency ablation 
at the same anatomic site is considered medically reasonable and necessary provided that the patient had a 
minimum of consistent 50% improvement in pain for at least six months OR at least 50% consistent 
improvement in the ability to perform previously painful movement and ADLs as compared to baseline 
measurement using the same scale. 
 
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 reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this request is for repeat radiofrequency ablation. The 70% pain relief from the last block in August 2021 
meets the criteria, and therefore, the request is deemed medically reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve repeat paravertebral facet joint radiofrequency ablation for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen and 
pelvis before and after contrast. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria for 
the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that the enrollee has a history 
of hematuria and interstitial cystitis. She had a prior hysterectomy with an unknown status of her ovaries. She 
has had a partial small bowel obstruction in the past. Her renal function appears normal but there is a concern 
of renal dysfunction. She has had a prior cholecystectomy. Cross sectional imaging is indicated based upon her 
history.  Due to her cachectic state, she likely is devoid of body fat which is an essential element to provide 
optimal computed tomography (CT) images. An MRI would allow for better visualization of her mesentery, 
common bile duct and biliary system as well her adnexae. As an aside there is mention of possible Multiple 
Myeloma in the records but contains no detail. Prior to the administration of Gadolinium, the safety of contrast 
administration should be addressed by clinicians as the presence of Myeloma may be a contraindication of a 
Gadolinium injection.  
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 magnetic resonance imaging (MRI) of the abdomen and pelvis before and after contrast.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the skilled nursing facility services. Our 
reviewer says that the skilled nursing facility services are not medically necessary at this time. Our physician 
reviewer found based on the provided records, the enrollee does not currently appear to be stable for discharge 
form the hospital. Additional treatment should be provided, after which re-evaluation is warranted to determine 
an appropriate placement. 
 
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 skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits. 
 
You asked the Plan to pre-approve additional acupuncture. You say that the only thing that has helped you find 
a small amount of relief has been acupuncture. The Plan denied your request. The Plan says all claims have 
been reviewed and its been determined that all 20 visits have been used. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, all 20 acupuncture visits have been used. Therefore, 
we decided that the Plan does not have to pre-approve additional acupuncture visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on November 18, 2021. 
 
You asked the Plan to pay for radiology services. You say that the patient is in a nursing home and you have an 
exclusive contract with the facility and are the only provider that can come into the facility to perform these 
services. The Plan denied your request. The Plan says services with an out-of-network provider require 
authorization. 
 
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 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 radiology services provided on November 18, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergency ambulance services provided on November 6, 2021, 
and November 11, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that these services have 
not been billed correctly. 
 
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. In this case, the Plan has denied coverage for these two claims stating that the 
U8 modifier is invalid and that a new claim is needed with a valid modifier. However, the claim forms that 
have been submitted do not indicate this modifier was billed or why these claims are different than the others 
that have been paid. Therefore, we decided that the Plan has to pay for the non-emergency ambulance services 
provided on November 6, 2021, and November 11, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility services. 
 
You asked the Plan to pre-approve the continued skilled nursing facility services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria for skilled nursing services 
is no longer met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continued skilled nursing facility 
services. Our reviewer says that the continued skilled nursing facility services are not medically necessary. Our 
physician reviewer found the enrollee has no daily skilled needs. The enrollee's needs can be met 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 continued skilled nursing facility services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued skilled nursing facility services.
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 the enrollee received oral and inhaled 
medications and had stable vital signs. An IVC filter was inserted for LLE DVT. She used oxygen via nasal 
cannula at baseline. The enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee does 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 5, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
should be paid as billed. The Plan denied your request. The Plan says this NGS panel was not billed with a 
single code. Therefore, the Plan has only approved payment for 11 of the 13 billed codes. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 5, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010, D6061, and D6057) provided 
by a participating provider. 
 
You asked the Plan to pre-approve dental implants. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says these services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants (D6010, D6061, and D6057) provided by a participating provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 160 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that the additional trips 
are medically necessary. The Plan denied your request. The Plan says 58 out of the allowed 60 trips have been 
used. Once the last 2 trips are utilized, the benefit will be exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 160 additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00400) billed for date of service 
February 10, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue were separate and distinct 
from the primary procedure. The Plan denied your request. The Plan says rules for payment have not been met 
because the services at issue are included in another billed code. 
 
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 00400 is "Anesthesia for procedures on the 
integumentary system on the extremities, anterior trunk and perineum; not otherwise specified." 
 
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 anesthesia services. Our reviewer says that the services at 
issue do not meet criteria for payment. Our reviewer found anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum, not otherwise specified, cannot be verified as the 
available medical records do not support an additional anesthesia service provided on the same date of service 
as the primary anesthesia 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 anesthesia services have not been met. Therefore, we decided that the Plan does 
not have to pay for anesthesia services (00400) billed for date of service February 10, 2022.
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 medically necessary. The Plan 
denied your request. The Plan says 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 the records show that the enrollee's needs can be met 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 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 a bone marrow aspirate procedure (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate procedure. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found more research is needed to show safety and efficacy of this procedure for 
the enrollee's condition. 
 
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 bone marrow aspirate procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bone marrow aspirate procedure (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 13, 2020, to 
November 17, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. The Plan denied your request. The Plan says 
according to Medicare guidelines, an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were 
furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient hospital care was not filed until March 14, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from November 13, 2020, to 
November 17, 2020.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says rules for coverage are not 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 the records show that the enrollee's needs can be met 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 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.