Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 the enrollee was admitted for lower gastrointestinal bleeding. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 skilled nursing facility (SNF) services from an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by a tertiary care provider. 
 
You asked the Plan to pre-approve an office visit. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is no medical necessity for the tertiary care provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is a tertiary provider and the services are available in-network at the 
community level. We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by a tertiary 
care provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83550, 84436, 84479 and 84480 billed for 
date of service February 14, 2022. 
 
You asked the Plan to pay for procedure codes 83550, 84436, 84479 and 84480. You say that these services are 
supported as billed. The Plan denied your request. The Plan says payment for codes 83550, 84436, 84479 and 
84480 is bundled into payment for codes 84439, 84466 and 84481. 
 
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, we have confirmed that codes 
83550, 84436, 84479 and 84480 are column II codes to column I codes 84439, 84466 and 84481 with a 
modifier indicator of 0. The column II codes are therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
83550, 84436, 84479 and 84480 billed for date of service February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 2, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 2, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from January 
2, 2023, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of January 2, 2023, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond January 2, 2023, as you were not a danger to yourself or others and 
did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from January 2, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 2, 
2023, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 8 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the 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 the therapy services. 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 while the 8 approved PT visits are shown to be reasonable and 
necessary, visits beyond this number are not 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 8 physical therapy (PT) visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transluminal peripheral atherectomy (0238T) provided on 
December 20, 2021. 
 
You asked the Plan to pay for the transluminal peripheral atherectomy. You say that you would like this service 
to be reviewed for reconsideration. The Plan denied your request. The Plan says experimental or investigational 
services are not 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 pay for the transluminal peripheral atherectomy. Our 
reviewer says that the transluminal peripheral atherectomy (0238T) is not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is not satisfactory documentation that supports the 
billing of code 0238T. The operative note is not provided and there is inadequate documentation that the work 
done to justify use of this code was performed. Our reviewer also found that while the documentation supports 
indications for treatment, the documentation is not sufficient to justify coverage of code 0238T.  
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 transluminal peripheral atherectomy have not been met. Therefore, we 
decided that the Plan does not have to pay for the transluminal peripheral atherectomy (0238T) provided on 
December 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the services requested are not medically 
necessary. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary (advanced) oncology services. 
 
You asked the Plan to pre-approve tertiary services. The Plan denied your request. The Plan says tertiary care 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 tertiary services. Our physician 
reviewer found that the enrollee has biopsy-proven squamous cell carcinoma of the parotid gland. There is no 
specific clinical rationale for referral to a tertiary care center for oncology services. The review has determined 
that the records do not show the requested services are 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 tertiary services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve tertiary (advanced) oncology services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not medically necessary. 
 
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 medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found the enrollee was hospitalized for a right total knee amputation (TKA) with multiple hospital 
complications and now with functional impairments. The records support that he has multiple medical 
complications that require daily skilled nursing services. He has functional impairments and skilled therapists 
recommend ongoing skilled therapy in a SNF. He requires physical assistance with self-care tasks and 
functional mobility; therefore, daily skilled therapy services are needed. As a practical matter, the enrollee 
requires the necessary services on an inpatient basis at the SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology service (88305) provided on March 23, 2022. 
 
You asked the Plan to pay for the pathology service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the pathology service have not been met. Per the Medicare 
guidelines the Plan is upholding the denial as the billed procedure codes 88305 have a physician Fee Schedule 
PCTC indicator of 1 and the claim a POS of 22 On Campus-Outpatient Hospital. The professional 
interpretation was furnished in the same payment locality from where the TC was furnished. The Medicare rule 
for payment of this claim has not been met as the professional interpretation of a diagnostic test must be 
separately billed with modifier 26 by the interpreting physician. Therefore, we decided that the Plan does not 
have to pay for the pathology service (88305) provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4 units of procedure code G0453 billed for date of service 
June 13, 2022. 
 
You asked the Plan to pay for 4 units of procedure code G0453. You say that the provided records support the 
services billed. The Plan denied your request. The Plan says the available records do not support the code at 
issue. 
 
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 G0453 is: Continuous intraoperative neurophysiology 
monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to 
one patient) each 15 minutes (list in addition to primary procedure). 
 
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 4 units of procedure code G0453. Our reviewer says that the reported number of units of the code at issue does not meet criteria for payment. Our reviewer found that the 
medical record documents 49 minutes of services. In this case, 4 units cannot be verified, as a minimum of 53 
minutes is not documented in the medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 units of procedure code G0453 have not been met. Therefore, we decided that 
the Plan does not have to pay for 4 units of procedure code G0453 billed for date of service June 13, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 5, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that the services are not supported by the records. 
 
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. 
 
Review of the file shows that the services are supported with the information provided. Therefore, we decided 
that the Plan has to pay for the laboratory services provided on October 5, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyperbaric oxygen under pressure (G0277) and physician 
attendance and supervision of hyperbaric oxygen (HBO) therapy (99183) provided on August 8, 2022. 
 
You asked the Plan to pay for the HBO therapy. You say that hyperbaric therapy services have been pre-
approved. You also say that these services have been paid on other claims. The Plan denied your request. The 
Plan says the services you received were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that reimbursement for hyperbaric oxygen (HBO) therapy 
will be limited to that which is administered in a chamber and is limited to the certain conditions, including 
diabetic wounds of the lower extremities which meet criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the HBO therapy. Our reviewer says that the 
requested HBO therapy is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee has a Wagner Grade III or higher lesion. Therefore, the reviewer found that 
the requested therapy is not medically reasonable or 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 HBO therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for the hyperbaric oxygen under pressure (G0277) and physician attendance and supervision of 
hyperbaric oxygen (HBO) therapy (99183) provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization. 
 
You asked the Plan to pre-approve a left heart catheterization. You say that the records provided support the 
need for the requested services. The Plan denied your request. The Plan says the requested services are 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 left heart catheterization. Our 
reviewer says that a left heart catheterization is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is asymptomatic, and an electrocardiogram (ECG) was interpreted as 
abnormal. Non-invasive stress testing has not been performed. 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 enrollee's 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 left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left heart catheterization.
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 requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting 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 the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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.