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

 
We decided that the Plan does not have to pre-approve 17 home health aide visits. 
 
You asked the Plan to pre-approve 17 home health aide visits. You say that these services are necessary for 
your condition. The Plan denied your request. The Plan says the criteria for coverage of home health aide 
services have not been met. 
 
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 17 home health aide visits. Our 
reviewer says that the requested home health aide visits are not medically reasonable and necessary. Our 
physician reviewer found that you have previously been receiving home health nursing, therapy and aide 
services. Provided records do not document a lack of caregivers in the home to necessitate further home health 
aide services beyond what have already been approved. No medical notes from your treating physician are provided documenting an order or need for additional skilled home health aide services. The requested services 
are not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 17 home health aide visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 17 home health aide visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) 
translocation analysis; minor breakpoint, qualitative or quantitative  (CPT code 81207) and BCR/ABL1 
(t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or 
quantitative (CPT code 81206) provided on December 1, 2021, by an out-of-network provider. 
 
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 the test at issue is investigative and 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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records demonstrate that the enrollee had a bone marrow biopsy suggesting 
leukocytosis. Without a diagnosis of a myeloid disease or myeloproliferative disorder, the requested tests are 
considered not medically necessary. The review has determined that all of the parts of the test are not 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; 
minor breakpoint, qualitative or quantitative  (CPT code 81207) and BCR/ABL1 (t(9;22)) (eg, chronic 
myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative (CPT code 81206) 
provided on December 1, 2021, by an out-of-network provider.
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for lower extremity weakness. 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, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking greater 
than household distances with a rolling walker with stand-by assistance and is stand-by assist for transfers. 
Provided records do not document a significant decline in your functional status to necessitate daily inpatient 
skilled therapy services. You do not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not document that services in the home or an assisted living facility with home health care 
or in a long-term care facility on a part time basis are not appropriate in this case. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Pharmacogenomic testing (81226, 81230, 81238, 81240, 
81241, 81291, 81335, 81407, 81408 and 81479) provided on March 16, 2021. 
 
You asked the Plan to pay for the Pharmacogenomic testing. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says one CPT code must be submitted for a 
panel. 
 The Plan must follow Medicare rules. Medicare rules say that if a lab runs more than two distinct procedural 
services on a single date of service, then the lab must use the 59 modifier with each additional service billed as 
an attestation that it is a distinct procedural service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Pharmacogenomic testing have not been met. Specifically, this claim has not been billed 
according to Medicare guidelines. Additionally, the documentation submitted does not include sufficient 
clinical information to determine why this testing was ordered and how it will affect the enrollee's treatment. 
Therefore, we decided that the Plan does not have to pay for Pharmacogenomic testing (81226, 81230, 81238, 
81240, 81241, 81291, 81335, 81407, 81408 and 81479) provided on March 16, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, hip, unilateral, with pelvis when 
performed; 2-3 views (CPT code 73502) provided on September 22, 2021. 
 
You asked the Plan to pay for the X-ray. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The modifier billed is not supported. Provider is billing the technical component modifier on this claim and the 
professional component on the related claim. Since both claims were billed to Physician's Mobile x-ray both 
claims should be denied. They should have billed with no modifier if billing for both components. Based on 
this information, we decided that Medicare rules for coverage of the X-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for the radiologic examination, hip, unilateral, with pelvis when 
performed; 2-3 views (CPT code 73502) provided on September 22, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for non-surgical management of a tibial plateau fracture. The enrollees medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc One injection (J7325). 
 
  You asked the Plan to pre-approve a Synvisc One injection. You say that the enrollee was given a steroid 
injection in 2016 by another provider that did not help her pain. You also say that you have the enrollee 
scheduled for a Synvisc One injection in the right knee due to osteoarthritis. The Plan denied your request. The 
Plan says other diagnoses have not been excluded by appropriate evaluation and management services, 
laboratory and imaging studies. The Plan also says that the magnetic resonance imaging reveals bilateral 
meniscus tears. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
of the conditions listed in the Medicare rules section above are met. 
 
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 Synvisc One injection. Our reviewer 
says that the elements of the coverage criteria are not satisfied, and the requested service cannot be 
recommended. Our physician reviewer found the record indicates that the enrollee has a diagnosis of knee pain 
relieved by Tylenol and meniscal tears and Chondromalacia without mention of osteoarthritis. Our reviewer 
found that the Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. There is no supportive citation for the use of the requested drug in the enrollee's clinical 
situation. Our physician reviewer also found that the record does not contain supportive radiographic 
confirmation of the presence of osteoarthritis. 
 
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 Synvisc One injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Synvisc One injection (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on June 24, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
considered inclusive to the primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 anesthesia 
services provided on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder detect test provided to the enrollee on January 
6, 2021. 
 
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 this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test.  
 
The denied test is not a covered benefit at this time. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. 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 
CxBladder detect test provided to the enrollee on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L3-S1 facet joint injection procedure coded as 
64495, 64494 and 64493. 
 
You asked the Plan to pre-approve the facet joint injection. You say that the enrollee has suffered from low 
back pain and has failed numerous therapies, medications, weight loss, lumbar facet radiofrequency 
(05/03/2021) and physical therapy. This injection is helpful for the enrollee's pain and life. The Plan denied 
your request. The Plan says records do not support that the requested procedure meets medically necessary 
criteria. 
 
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 facet joint injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, medical records were reviewed and showed that the requested facet 
injections are therapeutic.  There is no plan or consideration for a radiofrequency joint denervation/ablation 
procedure.  The most recent imaging provided shows that there is foraminal stenosis or narrowing of the spinal 
canal that potentially compresses the nerve roots.  Criteria for absence of untreated radiculopathy or no non-
facet pathology, that could potentially explain the source of the enrollee's pain, are not met. Criteria also 
require that the enrollee has had 2 medically reasonable and necessary diagnostic facet joint injections that 
have provided at least 80% or more relief of pain.  Coverage criteria have not been met as there was only one 
documented facet joint injection in 5/2021, without documentation of pain relief.  In addition, there was no 
documentation indicating that the enrollee is not a candidate for radiofrequency ablation. 
 
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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral L3-S1 facet joint injection procedure coded as 64495, 64494 and 64493.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 85060) provided on 
January 11, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory service (CPT code 85060) provided on January 11, 2022.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. All medically necessary care is being provided in the current acute care facility. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The health plan has approved ongoing care in the current acute care facility. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee. 
 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.