Persius/hicric huggingface dataset:
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 medically necessary, and it would 
be unsafe to discharge you. The Plan denied your request. The Plan says the services are not reasonable and 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 would like to be able to walk with a rolling 
walker and return to your assisted living facility. The Plan denied your request. The Plan says your request for 
an IRF admission does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cooled genicular nerve radiofrequency ablation (RFA) 
procedure (64624) provided on January 5, 2022. 
 
You asked the Plan to pay for the cooled genicular nerve RFA procedure. You say that the enrollee's physician 
found that the service performed would be beneficial to the enrollee's short and long-term health. The Plan 
denied your request. The Plan says genicular nerve ablation is considered investigational and not medically 
necessary for the treatment of chronic knee pain. 
 
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 cooled genicular nerve RFA procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found genicular nerve blocks and RFA are the subject of ongoing clinical 
trials to determine their role in the treatment of osteoarthritis of the knee. 
 
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 cooled genicular nerve RFA procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for the cooled genicular nerve radiofrequency ablation (RFA) 
procedure (64624) provided on January 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, additional 30 minutes (99292) billed for date of 
service May 12, 2022. 
 
You asked the Plan to pay for critical care. You say that 75 minutes of critical care were provided and therefore 
this service was reported appropriately. The Plan denied your request. The Plan says the first hour of critical 
care is defined as the first 30-74 minutes. One additional minute does not support the billing of an additional 
half hour of critical care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). The primary service, 99291, is defined as critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the record shows that 75 
minutes of critical care were provided on the date in question. Although 99291 is supported, 99292 is not. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care, additional 30 minutes (99292) billed 
for date of service May 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84425 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 84425. You say that a corrected claim has been sent for this 
service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 84425 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 84425 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 84425 billed for date of service May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and treatment to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a consultation and treatment to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a consultation and treatment 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 pre-approve a lower limb prosthetic flex-walk system and multi-
axial rotation unit. 
 You asked the Plan to pre-approve flex-walk system and multi-axial rotation unit. You say that this is 
medically necessary. The Plan denied your request. The Plan says a K3 foot exceeds the enrollee's needs, 
which may be met by a K2 prosthesis instead. 
 
The Plan follows Medicare rules. Medicare rules state that the need for lower limb prosthetic components is 
based on an assessment of the enrollees functional level. 
 
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 flex-walk system and multi-axial 
rotation unit. Our reviewer says that the enrollee does not meet criteria for the requested prosthetic 
components. Our physician reviewer found the records document the enrollee was a nursing home resident, but 
it is not clear if the enrollee continues to reside there. Records report the enrollee requires the ability to 
negotiate environmental barriers such as curbs and community obstacles, but do not document need for 
vocational, therapeutic, or exercise activities that demand prosthetic utilization beyond simple locomotion. It is 
not clear that a K2 level prosthesis would not meet the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flex-walk system and multi-axial rotation unit have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower limb prosthetic flex-walk system and multi-axial 
rotation unit.
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 enrollee requires continued services 
with a multi-disciplinary team approach that is experienced in working with chronically ill patients. The Plan 
denied your request. The Plan says the enrollee is currently at the appropriate level of care at Covenant 
Hospital, and the health plan will continue to cover your current hospital stay at this time. 
 
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 physician 
reviewer found that the acute hospital can provide for all the patients present inpatient care needs and the 
patient is receiving an appropriate level of care in the present setting. The provided records do not explain what 
care services will be provided in the LTACH that are not available in the present hospital setting. Continued 
care in the acute hospital is appropriate until the patient is stable to transfer to a lower level of care such as an 
inpatient rehabilitation facility, a sub-acute rehabilitation facility or 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 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 the services are medically necessary so that you can 
be closely monitored. The Plan denied your request. The Plan says that your needs can be met at a lower level 
of care such as a skilled nursing facility or at home with home health 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 there are no complex nursing or rehabilitation needs. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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: 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 services are the most appropriate 
level of care for the enrollee to receive the services needed. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and does not require transfer. 
 
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 enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF admission is medically necessary. The Plan 
denied your request. The Plan says the SNF admission you are requesting does not meet the requirements for 
approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs can 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 27, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab services 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 lab services provided on May 27, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99239 billed for June 3, 2022. 
 
You asked the Plan to pay for code 99239. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge day management services were provided on the date of service in 
question. Based on this information, we decided that Medicare rules for coverage of code 99239 have not been 
met. Therefore, we decided that the Plan does not have to pay for code 99239 billed for June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (A4253, A4256) provided on May 3, 2022 
to August 1, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed items. 
 
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 Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies (A4253, A4256) 
provided on May 3, 2022 to August 1, 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 you need this to regain your independence. The Plan 
denied your request. The Plan says this is not medically 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 your documented nursing, medical and rehabilitation needs would not be expected to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received from April 21, 2022, to May 12, 
2022. 
 
You asked the Plan to pay for the services. You say that you've never had to pay for these services. The Plan 
denied your request. The Plan says the provider must bill Medicare for these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The records show that you were under the Medicare hospice benefit for the dates of service at issue in this 
appeal. The provider must bill Medicare directly for these services. Therefore, we decided that the Plan does 
not have to pay for the services you received from April 21, 2022, to May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 4, 2022.