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

 
We decided that the Plan does not have to pre-approve the home health services. 
 
You asked the Plan to pre-approve the home health services. You say that the home health services requested 
are medically necessary. The Plan denied your request. The Plan says the home health services requested are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer 
says that the home health services requested are not medically necessary. Our physician reviewer found 
provided records document weakness, unstable gait, difficulty with transfers and activities of daily living after 
hospitalization for a stroke in June 2022 but there are no medical records from the enrollee's treating physician 
documenting an order or need for skilled home health nursing services.  
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on May 5, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the billed date of service was inappropriate. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that the date of 
service for clinical laboratory tests must be the date that the specimen was collected. However, there are 
exceptions.  
 
The date of service can be the date the specimen was tested when the service is an Advanced Laboratory 
Diagnostic Test (ADLT), and the services were rendered while outpatient. There is no evidence that this 
service was done while the enrollee was inpatient. The test is an ADLT. Based on this information, we decided 
that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay 
for laboratory services provided to the enrollee on May 5, 2022.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 documentation does not support necessity for admission to an IRF. While the 
enrollee may benefit from continued physical and occupational therapy, the enrollee's rehabilitation needs can be safely provided in a lower intensity and alternate 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 inpatient rehabilitation facility (IRF) admission and 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 the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the medical records submitted do not establish 
that the admission to an Inpatient Rehabilitation Facility is reasonable and necessary. 
 
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 on review of the available records, the enrollee is medically stable and does not need PMR physician's supervision 3 times a week in an IRF. No acute rehab nursing needs were identified or 
documented. At the current functional level, the enrollee does not need intensive therapies consisting of at least 
3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. Document does 
not support necessity for admission to an IRF. While the enrollee may benefit from continued PT, and OT, the 
enrollee's rehab needs can be safely provided in a lower intensity and alternate setting such as in an SNF or in -
home with services. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
February 17, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says validity testing is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 for date of service February 17, 2022.
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 enrollee is unable to walk on their own and is a 
heavy assist. The enrollee needs extensive therapy to be able to function on their own. This is getting 
progressively worse and without therapy the enrollee may lose all function to walk. The Plan denied your 
request. The Plan says the enrollee's condition does not meet the Medicare guidelines. The enrollee's needs can 
be met at an assisted living facility with home health services or in a long-term care setting with part time 
skilled services. 
 
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 is medically stable and does not need PMR physician's supervision 3 
times a week in an IRF. No acute rehab nursing needs were identified or documented. At the current functional 
level and preadmission needing assistance, the enrollee does not need intensive therapies consisting of at least 3 
hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. Document does 
not support necessity for admission to an IRF. While the enrollee may benefit from continued physical therapy 
and occupational therapy, the enrollee's rehab needs can be safely provided in a lower intensity and alternate 
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 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) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 the enrollee did not require skilled therapy to establish a safe and effective 
maintenance program.  As a practical matter, the enrollee did not require any skilled services on an inpatient 
basis, at a skilled nursing facility level of care at the time of discharge from the hospital. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enterolysis and surgical services provided to the enrollee on 
February 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says enterolysis and surgical services provided to the enrollee on February 9, 2022. 
 
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 the denied codes is: 
 
CPT 44005: 
 
Enterolysis (freeing of intestinal adhesion) (separate procedure) 
 
CPT 49561: 
 
Repair initial incisional or ventral hernia; incarcerated or strangulated  
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of procedure code CPT 49561 with the use of modifier 59. The description of the procedure 
was inclusive to performed CPT code 44120. The medical records do not support the use of procedure code 
44005 with the use of modifier 59 as the procedure code 44120 includes the process of enterolysis that would 
be captured with procedure code CPT 44005. 
 
We looked at this coder'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 pay for enterolysis and surgical services provided to the enrollee on February 9, 2022.
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 the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that enrollee requires assessment by skilled nursing, 
and evaluating therapists recommend daily skilled therapy services. Thus, from a practical standpoint, daily 
skilled services on an inpatient basis in a skilled nursing facility is 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005, 93041, and 94761 provided on May 
17, 2022. 
 
You asked the Plan to pay for procedure codes 93005, 93041, and 94761. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that procedure codes 93005, 93041, and 94761 are not supported in the medical record. Specifically, 
code 99285 (emergency department visit) was billed on the same date of service, with revenue code 450. This 
code has a status indicator of "V". Therefore, this makes codes 93005, 93041, and 94761 not separately 
payable. Therefore, we decided that the Plan does not have to pay for procedure codes 93005, 93041, and 
94761 provided on May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 12001. You say that this code should be paid. The Plan denied 
your request. The Plan says payment for code 12001 is bundled into payment for code 12011. 
 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 code 12001 
is a column II code to column I code 12011. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 12001 billed for date of service April 7, 2022.
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. The Plan denied your request. The Plan says the enrollee's 
medical and therapy needs could be met in a skilled nursing unit. 
 
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 no acute rehab nursing needs were identified. 
While the enrollee may benefit from continued physical or occupational therapy, the enrollee's rehab needs can 
be safely provided in a lower intensity 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint ablations. 
 
You asked the Plan to pre-approve facet joint ablations. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who meet specific 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 pre-approve facet joint ablations. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the radiofrequency ablation (RFA) 
did not produce sustained pain relief. There is no indication to repeat it. The request 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 facet joint ablations have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint ablations.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says criteria for this device are not met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the ventilator is not considered medically necessary. Our physician reviewer found this enrollee has chronic 
obstructive pulmonary disease (COPD) and obesity. Blood gas testing at baseline shows mild carbon dioxide 
retention. The documentation supports that the enrollee may benefit from bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) during sleep, but Medicare does not cover 
ventilators for this purpose.  
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 clinical documentation shows that you have ongoing medical monitoring needs and 
would require the professional assessments skills of a registered nurse. You have documented functional 
impairments and would require the treatment by skilled therapy. However, there is no documentation to show 
that you require daily services on an inpatient basis. 
 
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.