Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on February 8, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says they do not pay for at-home COVID-
19 tests. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test is an OTC item. The test was purchased prior to when Medicare started a new initiative to 
cover up to eight over-the-counter COVID-19 tests. Therefore, we decided that the Plan does not have to pay 
for the at-home COVID-19 tests purchased on February 8, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the records show that it is not reasonable to expect that the enrollee will be able to 
safely participate in, or fully benefit from, the intensity of services of an IRF. The enrollee is not able to take 
part in 3 hours of therapy a day at least 5 days a week or 15 hours per week. The enrollee can safely receive the 
services needed in other settings, for example: a skilled nursing facility, home with home health services or 
perhaps home with outpatient therapy. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status. The enrollee can receive further services 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 IRF admission and services.
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 the denial of authorization for 
skilled nursing facility admission. The Plan denied your request. The Plan says you do not meet criteria for 
SNF admission. 
 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 you are at a contact guard assist level with functional mobility including gait to 116 
feet. You required varying assist with activities of daily living skills. You do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found you do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous 
(CPT code(s): 37226, 37225, 37224, 37227). 
 
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 records do not show that the enrollee has blockages in their legs that would explain 
their pain. 
 
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found no rationale is provided describing the need for, or the plan to, proceed with lower extremity 
angiography and possible intervention. 
 
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 revascularization, endovascular, open or percutaneous (CPT code(s): 37226, 37225, 
37224, 37227).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition they do not meet the 
requirements for approval. 
 
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 was admitted to the acute care hospital with acute respiratory failure, 
pneumonia, pulmonary edema requiring mechanical ventilation support, antibiotics, and complicated by a 
gastrointestinal bleed and need for wound care. Recent notes describe the enrollee as not tolerating a trach 
collar and responding overall to current treatments.  
 
 The enrollee appears to be more stable and improving and should only require short-term additional acute care 
services that can be safely administered at the current facility until more appropriate for a lower level of care. 
The enrollee does not require services at the LTACH that are not available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography of the head or brain (70450), the 
Radiologic examination of the chest (71045), and the Computed tomography of the abdomen and pelvis 
(74176) provided on April 20, 2022. 
 
You asked the Plan to pay for codes 70450, 71045, and 74176. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the 
services billed. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Computed tomography of the head 
or brain (70450), the Radiologic examination of the chest (71045), and the Computed tomography of the 
abdomen and pelvis (74176) provided on April 20, 2022, have been met. The file includes evidence that the 
items/services at issue were reimbursed by the Plan on May 19, 2022. There is no evidence presented to 
support that the billed items/services were provided twice on the same date. Therefore, we decided that the Plan 
does not have to pay for the Computed tomography of the head or brain (70450), the Radiologic examination of 
the chest (71045), and the Computed tomography of the abdomen and pelvis (74176) provided on April 20, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 29, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) 
code 83789-59 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
  
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) 
code 83789-59 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 66494). 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee is in constant pain and needs 
these injections. The Plan denied your request. The Plan says there is no indication from your medical record 
that these pathologies (grade II anterolisthesis, central canal stenosis and effacement/entrapments of multiple 
nerve roots) have been addressed. The enrollee does not meet the requirements for approval. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic axial low back pain. He underwent diagnostic facet blocks 
and had 80% pain relief for the duration of the analgesic and 60% pain relief for 5 days following the 
procedure. Afterwards, physical therapy exacerbated the pain. Magnetic resonance imaging (MRI) findings of 
lumbar spondylosis with a grade II anterolisthesis of L5 on S1 due to a pars defect resulting in central canal 
stenosis with effacement of the exiting S1 nerve roots and compression of the exiting L5 nerve roots. The 
request is to repeat the blocks. Therefore, the presence of these other pathologies results in the request do not 
meet approval for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 66494).
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 you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet the requirements for approval. 
 
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 you had a stroke in February 2022. You have severe aortic stenosis, dementia, 
and general debility. You were recently hospitalized with confusion thought to be a consequence of a urinary 
tract infection. You are deconditioned and need to regain strength. You do not require intensive rehabilitation 
or physiatry oversight. The chronicity of your condition, your aortic stenosis and dementia limit your ability to 
respond to intensive rehabilitation and benefit from it. You neither require nor can benefit from intensive 
therapy. 
 
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: 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 the denial of services in a skilled 
nursing facility. The Plan denied your request. The Plan says based on the additional information available, you 
do not meet the criteria for admission to a SNF facility. 
 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 you are at a maximal assist of two for bed mobility and require a mechanical lift for 
transfers at baseline. You also require assist with activities of daily living skills. You do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found you do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) 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: 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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain his functional status. The enrollee can receive further services 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 22, 2022, billed with 
codes 81206, 81210, 81235, 81275, 81292, 81301, 81317, 81401, and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the claim has not been billed in 
accordance with Medicare billing regulations. 
 
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 
March 22, 2022, billed with codes 81206, 81210, 81235, 81275, 81292, 81301, 81317, 81401, and 81194.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 26, 2021, billed with 
codes 81408, 81249, 81230, 81291, 81226, 81225, 81241, 81240 and 8133. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
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 
August 26, 2021, billed with codes 81408, 81249, 81230, 81291, 81226, 81225, 81241, 81240 and 8133.
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 SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have 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 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 based on the documentation provided, the enrollee does not have documented 
skilled nursing needs. In addition, the enrollee does not have documented skilled therapy needs. The enrollee is 
ambulating household distances. Daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of the enrollees 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.