Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits. 
 
You asked the Plan to pre-approve home health aide visits. You say that you have complicated health issues. 
You say that you cannot be left unattended. You say that you live with your son who is unemployed but is 
limited to the areas in which he can assist you. You also say that you require additional assistance. The Plan 
denied your request. The Plan says the requested home health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide visits. Our reviewer 
says that the requested home health aide visits are not medically necessary. Our physician reviewer found the 
provided documentation does not support that you require skilled nursing services or skilled rehab services to 
provide treatment that is medically necessary.  The reviewer found that you do not require skilled nursing or rehab services to effectively provide treatment, 
care, and/or services in order to improve your condition, perform a maintenance program to maintain your 
condition and/or prevent deterioration. The reviewer found that you have been medically stable without any 
recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer found that the 
requested home health services 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 home health aide visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on February 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99292 is 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 code 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, there is no documentation of 
an additional 30 minutes of critical care services spent on the enrollee. 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 pay for the critical care services rendered on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 June 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has not met goals and is 
debilitated. The Plan denied your request. The Plan says ample time has been provided to establish a home 
exercise program. 
 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. 
 
The file shows that 11 home health physical therapy services were requested. The Plan agreed to pre-approve 2 
visits. 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 services. Our physician 
reviewer found that in this case, the documentation does not support that the enrollee requires additional skilled 
rehabilitation services. Skilled rehabilitation services are not required to effectively provide treatment in order 
to improve the enrollees condition or perform a maintenance program to maintain her condition or prevent 
deterioration. She has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. Therefore, the requested home health services 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on September 21, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
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 code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes". 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 
30-74 minutes of critical care services were provided on the date of service in question. 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 critical care services (99291) provided on September 21, 
2021.
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. The 
Plan denied your request. The Plan says authorization denied because LTACH is not medically necessary and 
the enrollee's needs can be met at a lower level of care, such as a skilled nursing facility when he is stable to 
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 the 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 they 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment, spinal, three or four 
regions (98941) provided September 7, 2021 to October 4, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that this facility is the only place in the 
country that provided these services for your chronic pain conditions. The Plan denied your request. The Plan 
says routine maintenance therapy is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to 
pay for the chiropractic manipulative treatment, spinal, three or four regions (98941) provided September 7, 
2021 to October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac catheterization. 
 
You asked the Plan to pre-approve a cardiac catheterization. You say that this procedure is medically necessary 
for your medical condition. The Plan denied your request. The Plan says the left heart catheterization is 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 pre-approve a cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is the medical appropriateness and necessity for performance of cardiac 
catheterization. You had a negative radionuclide stress test in December 2021. Notes from a March 2022 office 
visit indicate no angina or congestive heart failure symptoms. Documentation does not support the rationale for 
this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting. As a 
result, at this time cardiac catheterization would not be considered medically appropriate and necessary in this 
patients clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardiac catheterization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided on 
May 28, 2021. 
 
You asked the Plan to pay for hospital discharge day management services. The Plan denied your request. The 
Plan says despite multiple outreaches by the Plan, this provider has not submitted any clinical records to 
support the medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say to consider coverage and payment for any item or 
service, the information submitted by the supplier or provider must corroborate the documentation in the 
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met 
 We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents 
to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for hospital discharge 
day management services provided on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural injection services. 
 
You asked the Plan to pre-approve epidural injection services. You say that these injections are medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the records do not show that 
the enrollee's pain has failed to improve following a four-week trial of standard treatment methods. 
 
The Plan must follow Medicare rules. Medicare rules say that ESIs should be performed in conjunction with 
conservative treatments. Patients should be part of an active rehabilitation program, home exercise program or 
functional restoration program. 
 
We looked at the file and Medicare rules. In this case, there is no evidence that the enrollee is currently 
involved in conservative treatments of any kind. Based on this information, we decided that Medicare rules for 
coverage of epidural injection services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve epidural injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282) sales tax (S9999) purchased September 27, 
2021 from an out of network provider. 
 
You asked the Plan to pay for the wig. You say that you had contacted the Plan prior to purchasing the wig and 
was told that it would be covered. The Plan denied your request. The Plan says cosmetic surgery or procedures 
are not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) sales 
tax (S9999) purchased September 27, 2021 from an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs and completed a course of IV antibiotics. There are no identifiable skilled 
nursing service needs or skilled therapy service needs. 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 28, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
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 the lab services provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the repeat ESI. You say that the enrollee would benefit from an additional 
injection to allow for more pain relief. The Plan denied your request. The Plan says Medicare does not cover a 
repeat injection when pain relief has not lasted at least 3 months. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESIs may be covered when prior injection 
provides at least 50% pain relief for at least 3 months. 
 
We looked at the file and Medicare rules. The enrollee received 98% relief from an injection provided in 
January 2022, but pain was beginning to return within several weeks. This repeat ESI was requested and denied 
in the beginning of February 2022. In order to qualify for coverage of a repeat ESI, documentation must show 
that the pain relief remains about 50% until at least early April 2022. If this is documented, another request can 
be made at that time. However, based on this information available at the time of this request, we decided that 
Medicare rules for coverage of the repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43255) and a 
colonoscopy (45385). 
 
You asked the Plan to pre-approve an esophagogastroduodenoscopy and a colonoscopy. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
medical necessity rules for the requested services have not been met. 
 
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 an esophagogastroduodenoscopy and a 
colonoscopy. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that, according to the provided medical records, a 
colonoscopy is considered a medically necessary service for conditions and scenarios that are not present in the 
enrollee's case. Additionally, the documentation does not support that an esophagogastroduodenoscopy is 
medically reasonable and necessary for the enrollee at this time. If the enrollees upper chest squeezing spasm 
is evaluated and a cardiac cause is excluded, an esophagogastroduodenoscopy may be considered at that time. 
 
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 esophagogastroduodenoscopy and a colonoscopy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43255) and 
a colonoscopy (45385).