Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85025 and 80050 billed for date of service 
June 30, 2020. 
 You asked the Plan to pay for procedure codes 85025 and 80050. The Plan denied your request. The Plan says 
these codes are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that code 80050 (general 
health panel) is considered a non-covered code. 
 
In this case, we have confirmed that code 85025 is a column II code to column I code 85027. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. You have also requested payment for services billed under code 80050. Medicare 
does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to 
pay for procedure codes 85025 and 80050 billed for date of service June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization for treatment of knee 
osteoarthritis (CPT code(s): 37242 x6, 37243 x6, 36247 x6, 36248 x6, 76937 x6). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there are not enough studies on geniculate artery embolization for treatment of knee 
osteoarthritis to show it is safe and effective; therefore, it is not considered "standard of care." 
 
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 there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. While the studies are noted to be 
promising, further studies/research is needed to corroborate that geniculate artery embolization is as good as or 
better than standard treatments for knee osteoarthritis. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested geniculate artery embolization for treatment of knee osteoarthritis, in this case, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve geniculate artery embolization for treatment of knee osteoarthritis (CPT code(s): 37242 x6, 
37243 x6, 36247 x6, 36248 x6, 76937 x6).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumex LF2020 Easy Lift Sit-to-Stand (sit to stand lift). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says the easy lift sit to stand device would not allow for independent transferring. The Plan states you 
were recommended to transfer with a Hoyer lift and the requested sit to stand device is not medically necessary 
and the device is not reasonable and necessary for your condition as it would not allow for independent 
transferring. The Plan states you would still require a Hoyer lift for transfers. 
 
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 item. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device is used to assist an individual transfer who is able to assist with the 
transfer itself. The physical therapist has recommended you be transferred by a mechanical lift as you are not 
able to consistently and safely participate in transferring yourself. The requested device has not been shown to 
be superior to other standard treatments for the medical condition. The studies do not indicate the Easy Lift 
improves an individuals function or general health. The requested device is 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lumex LF2020 Easy Lift Sit-to-Stand (sit to stand lift).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third session of radiofrequency ablation (RFA). 
 
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 request exceeds the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months.  
 
We looked at the file and Medicare rules. The request is for a third RFA session at the same level. 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 a third session of radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Austedo. 
 
You asked the Plan to pre-approve Austedo. You say that the enrollee has Tardive dyskinesia and needs the 
requested drug in order to control movements. The Plan denied your request. The Plan says the requested 
medication does not fall under Part B coverage. The Plan says that they do not administer pharmacy benefits 
for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Austedo.  
 Benefits for Austedo may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, sacroiliac joint, percutaneous or 
minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when 
performed, and placement of transfixing device (CPT code 27279). 
 
You asked the Plan to pre-approve the arthrodesis. You say that the enrollee may benefit from injection with 
present pain and discomfort. The Plan denied your request. The Plan says the enrollee's records do not show 
confirmation of sacroiliac joint etiology via pain relief of at least 50% (ie, on visual analogue scale) from 
needle injection of local anesthetic into sacroiliac joint. 
 
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 arthrodesis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not show confirmation of sacroiliac joint etiology via pain relief of at least 50% 
(i.e., on visual analogue scale) from needle injection of local anesthetic into sacroiliac joint. 
 
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 arthrodesis have not been met. Therefore, we decided that the Plan does not have to pre-approve the arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device (CPT code 27279).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level of injection provided to the enrollee on 
April 14, 2022. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says the provider did not send in evidence of a unique circumstance to necessitate a third 
level of injection. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the third level exceeds the utilization criteria. There is no documentation of any unique or 
exceptional circumstances for a third level of injection. The third level is deemed not 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a third level of injection provided to the enrollee on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 or 3 power wheelchair with multiple power 
options (K0842/K0861), a power tilt and recline (E1007), and accessories (E1012, E2311, E2377, E2313, 
E2361, E1028, E0955, E2603). 
 
You asked the Plan to pre-approve a group 2 or 3 power wheelchair with multiple power options, a power tilt 
and recline, and accessories. You say that these items are medically necessary. The Plan denied your request. 
The Plan says the enrollee does not meet the requirements for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 or 3 power wheelchair with multiple power 
options will be covered if the beneficiary either uses a ventilator which is mounted on the wheelchair or meets 
coverage criteria for a power tilt and recline seating system and the system is being used on the wheelchair.  
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 group 2 or 3 power wheelchair with 
multiple power options, a power tilt and recline, and accessories. Our reviewer says that the requirements for 
coverage of the requested items have not been met. Our physician reviewer found the submitted records do not 
document that the enrollee uses a ventilator. The records also do not support that the enrollee is high risk for 
skin breakdown, has a history of pressure ulcers, or has had skin flap surgery. There is no documentation that 
the enrollee performs bladder self-catheterization and is unable to transfer independently or that the patient has 
increased muscle tone or spasticity. Thus, the enrollee does not meet coverage criteria for a power tilt and 
recline seating system. 
 
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 group 2 or 3 power wheelchair with multiple power options , a power tilt and 
recline, and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 2 or 3 power wheelchair with multiple power options (K0842/K0861), a power tilt and recline (E1007), 
and accessories (E1012, E2311, E2377, E2313, E2361, E1028, E0955, E2603).
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 that the enrollee requires skilled interdisciplinary 
physical therapy, occupational therapy, and speech services. You say that the services the enrollee needs they 
cannot receive in a subacute level of care. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as a skilled nursing facility. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not qualify for SNF coverage. There are no documented skilled 
nursing or skilled therapy needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the member does not 
meet the Medicare criteria for LTACH services. 
 
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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to 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 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: 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 you and your physician are in favor of rehabilitation 
and deem it medically necessary at this time. The Plan denied your request. The Plan says you do not meet the 
criteria for an inpatient rehabilitation facility (IRF) stay and are able to receive care in an alternate setting, such 
as a skilled nursing facility. 
 
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 you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided March 30, 2022, to April 
27, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that the admission date on the NOA must always match the 
From date on the claim. 
 
Review of the file shows that the a valid NOA was submitted with an admission date of January 29, 2022. The 
claim shows a date of service from March 30, 2022, to April 27, 2022. Since the first date of service for the 
plan year 2022 was January 29, 2022, this would be the correct admission date to be entered on all subsequent 
final claims. As the final claim was submitted with invalid information, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided March 30, 
2022, to April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing, medical and rehabilitation documented needs would require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. IRF criteria met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that the enrollee is currently undergoing treatment at a short-term acute-care hospital 
(STACH). There is no evidence that the enrollee requires services that are not currently available. As LTACHs 
and STACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to 
the LTACH. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.