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

 
We decided that the Plan does not have to pre-approve the SNF continuation of care. 
 
You asked the Plan to pre-approve the SNF continuation of care. You say that the enrollee could be further 
rehabilitated but has not been provided an adequate chance to be. You say the enrollee is not well enough to go 
home but could be well enough if given the appropriate physical therapy to address her balance. The Plan 
denied your request. The Plan says based on a review of the additional information received, it was determined 
that the enrollee does not meet the criteria for coverage to extend the stay at the SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF continuation of care. Our 
reviewer says that the provided records do not document a significant decline in the enrollees functional status 
to necessitate further daily inpatient skilled therapy services. Our physician reviewer found the enrollee has a 
past medical history of diabetes, hypertension, asthma and chronic kidney disease who was admitted to a 
skilled nursing facility for skilled nursing and therapy services on August 1, 2022 after treatment in an acute 
hospital for a fall. The enrollee was weak and deconditioned and was working with physical and occupational 
therapy. As of August 22, 2022, the enrollee was walking 200 feet with a rolling walker with supervision to 
contact guard assistance and was stand-by assist for transfers and supervision to minimum assist for activities 
of daily living. The enrollee otherwise was reported to be medically stable for discharge to long term care on 
outpatient medications. The last covered day in the skilled nursing facility for skilled nursing and therapy 
services was August 24, 2022. 
 
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. Our reviewer also found that 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 the SNF continuation of care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SNF continuation of care.
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. You say that the enrollee needs SNF. 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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in 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 SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF services after August 10, 2022. 
 
You asked the Plan to pre-approve continued SNF. You say that the enrollee needs continued SNF. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for continued SNF care after August 10, 
2022. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extended SNF stay.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on October 5, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
included when billed on the same day as a minor surgery procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code 99285 was provided on the same date of service as a minor surgical procedure. The 
code at issue was not billed with a modifier to indicate a separately reportable visit. 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 emergency room services provided on October 5, 2021.
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. You say that you need SNF care. 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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in 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 SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychological testing evaluation provided on  
December 23, 2021. 
 
You asked the Plan to pay for the psychological testing evaluation. You say that the psychological testing 
evaluation was medically necessary. The Plan denied your request. The Plan says the psychological testing 
evaluation was 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 pay for the psychological testing evaluation. Our 
reviewer says that the psychological testing evaluation is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the record provided does not document the medical necessity of 
the services provided. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.   
 
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 psychological testing evaluation have not been met. Therefore, we decided 
that the Plan does not have to pay for a psychological testing evaluation provided on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on June 14, 2021. 
 
You asked the Plan to pay for the services provided. You say that the guidelines do not require a modifier. The 
Plan denied your request. The Plan says the Medicare rule for payment has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the pathology testing was provided to a hospital inpatient. 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 pathology services provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 15, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says it is unable to 
determine if the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. We looked at the file and Medicare rules. In this case, there are no medical records from the treating physician 
to show the results would be used in the treatment of a specific medical problem. The records do not show the 
physicians intent for the testing to be completed. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the gene 
panel testing provided on January 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) services provided on 
November 8, 2021. 
 
You asked the Plan to pay for the RFA services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA services are only covered for certain indications. 
 
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 RFA services. Our reviewer says that the 
documentation does not support that the services rendered were medically reasonable or necessary. Our 
physician reviewer found the enrollee has sacroiliitis. The enrollee has tried medication trials of Oxycodone, 
Acetaminophen, Xtampza, Lyrica, and Amitriptyline. The procedure rendered is considered experimental/ 
investigational because of the wide variation in efficacy as reported in the literature. Therefore, the enrollee did 
not meet criteria for the services rendered. 
 
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 RFA services have not been met. Therefore, we decided that the Plan does 
not have to pay for the radiofrequency ablation (RFA) services provided on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested HFCWOD is not medically reasonable and necessary. Our physician reviewer found that the enrollee 
has a diagnosis of COPD. There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease.  There is inadequate evidence that HFCWOD is beneficial in the treatment of COPD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
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 the enrollee's condition they do not meet the requirements. 
 
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 to an acute hospital on August 18, 2022 for an elective 
revision of right total knee arthroplasty. The enrollee tolerated the procedure without complications.  As of August 25, 2022 the enrollee is medically stable and pain well controlled. The enrollee is medically 
stable and no other acute medical issues documented. Comorbid conditions are all stable. There are no complex 
nursing or rehabilitation needs. While the enrollee has need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. The enrollee's needs can be safely provided in 
an alternate and low intensity setting such as in 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the left ankle brace and heel stabilizer provided on March 18, 
2022. 
 
You asked the Plan to pay for the left ankle brace and heel stabilizer. You say that these items would have been 
paid by Original Medicare. The Plan denied your request. The Plan says the records do not support the need for 
these items. 
 
The Plan must follow Medicare rules. The rules state that if the information in the patients medical record does 
not adequately support the medical necessity for the item, the supplier is liable.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, there is nothing in the patient's medical records discussing any conditions related to 
the left ankle.  Further, even the physician order/prescription you supplied only addresses conditions affecting the right ankle, not the left. Therefore, we decided that the Plan does not have to pay for the left ankle brace 
and heel stabilizer provided on March 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this procedure is medically necessary and 
supported by strong science. The Plan denied your request. The Plan says this is experimental and 
investigational. 
 
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 this procedure is experimental. More research is needed to show safety and efficacy. 
 
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 the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a specialist (99203) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with a specialist. You say that you have requested a 
consultation with the OON provider because he is close to your residence, and you have difficulty traveling. 
The Plan denied your request. The Plan says the requested provider is not a network provider. You must 
receive your care from a network 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 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 
an office visit with a specialist (99203) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis, sagittal-coronal control, with rigid 
anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral 
strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on 
intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen 
design, prefabricated, off-the-shelf provided on March 18, 2022. 
 
 
 You asked the Plan to pay for a lumbar-sacral orthosis. You say that the claim met all of the Medicare 
guidelines for payment. the enrollee had a face-to-face visit within 6 months of the script that was signed by the 
same doctor, the DME was shipped using signature required service and proof of deliver was added to the 
records. The provider would like the records to be reviewed and the claim to be reprocessed and paid. The Plan 
denied your request. The Plan says the March 1, 2022, medical record does not state that the provider 
prescribed, or considered, a back brace for this enrollee. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the follow up visit on March 1, 2022, was for a trigger point injection and 
recurring mid back pain. Additional injections for a trigger point and home care instructions were given. 
During that follow up visit, no mention of a back brace for the enrollee was made. Therefore, we decided that 
the Plan does not have to pay for a lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and 
posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength 
provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, 
includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-
the-shelf provided on March 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcendental meditation classes you received from January 
9, 2022, to April 9, 2022. 
 
You asked the Plan to pay for the transcendental meditation classes. You say that transcendental meditation 
was recommended to you due to your anxiety and insomnia.  You said that you were told that you could submit 
these bills for reimbursement. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that transcendental meditation is not a Medicare-
covered service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transcendental meditation classes have not been met. Therefore, we decided that the Plan does 
not have to pay for transcendental meditation classes you received from January 9, 2022, to April 9, 2022.