Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, a procedure that uses 
heat from the tip of an electrical probe that vibrates to destroy a nerve in the neck or mid back for pain relief 
(CPT code 64633). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is having back pain due to thoracic 
fracture, the enrollee reports low back pain that radiates to the right status post fall, and the enrollee can only 
walk or stand for less than five (5) minutes due to the severe pain and unsteady gait. You state you would like 
this procedure approved for the enrollee because they would like to improve their quality of life. The Plan 
denied your request. The Plan says the enrollee does not meet medical necessity criteria for radiofrequency 
ablation (RFA) due to pain present less than three (3) months, no documentation of that other sources of the 
enrollee's pain have been ruled out including fracture (which the enrollee is documented to have at the location 
of proposed RFA), and no diagnostic or therapeutic medical branch blocks done that provided at least 80% pain 
relief thereby confirming that facet joint is the truly the source of the enrollee's pain. 
 
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 service. Our physician reviewer 
found it is NOT standard of care to perform neurolysis at the same time as a Kyphoplasty and the enrollee has 
not had any diagnostic blocks. 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, a procedure that uses heat from the tip of an electrical 
probe that vibrates to destroy a nerve in the neck or mid back for pain relief (CPT code 64633).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and services of home health aide (HHA) (G0156). 
 You asked the Plan to pre-approve skilled nursing services and HHA services. The Plan denied your request. 
The Plan says the documentation submitted reflects these services are custodial in nature. The Plan also says 
that the health plan has not received any evidence proving the need for home health services. 
 
The Plan must follow Medicare rules. The rules say that the patient's plan of care must reflect the physician or 
allowed practitioner ordered services that the home health agency provides either directly or under 
arrangement. 
 
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 skilled nursing services and HHA 
services. Our reviewer says that you do not meet the criteria for coverage for the skilled nursing services and 
HHA services. Our physician reviewer found based on the documentation, you would appear to benefit from 
skilled nursing services for medical monitoring of blood pressure, poly-pharmacy and skin breakdown checks, 
as you have chronic incontinence and aid services to help with bathing (as documented). Our reviewer found 
that there is no ordering provider for home health services. Our physician reviewer also found that home health 
services require an ordering provider per Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing services and HHA services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and services of home health aide (HHA) (G0156).
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. Although the enrollee is 
limited functionally, provided records do not document a significant decline in the enrollees functional status 
compared to her recent baseline to necessitate daily inpatient skilled therapy services. The enrollee does not 
require the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document 
that services in the home 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy (PT) visits (97110 x12). 
 
You asked the Plan to pre-approve the PT visits. You say that you would like therapy to be continued for this 
enrollee. The Plan denied your request. The Plan says the notes do not show that physical therapy is required to 
maintain function or prevent regression of function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there is no documentation that the requested therapy is generally 
accepted as specific and effective therapy for the patients condition. Our reviewer found that there is no 
documentation that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist or under the supervision 
of a therapist. Our physician reviewer also found that based on the medical records provided there is no 
documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to 
establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 physical therapy (PT) visits (97110 x12).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the patient is not enrolled in a Medicare-approved clinical study looking at the benefits 
of spacer devices in lumbar spinal stenosis. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with 
neurogenic claudication. The record indicates that the imaging demonstrates mild to severe multi-level 
foraminal stenosis. The record does not document that the enrollee is not indicated for further surgery at more 
than two levels. 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device for the 
enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chiropractic manipulative treatments provided from January 12, 2021, 
through September 10, 2021. 
 
You asked the Plan to pay for chiropractic manipulative treatments. You say that you started the claims process 
and have yet to receive any communication. The Plan denied your request. The Plan says that the services are 
denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any information why the claim was 
denied or rationale to support their denial of this claim. It is the burden of the Health Plan to substantiate their 
denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for chiropractic manipulative treatments provided from January 
12, 2021, through September 10, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no expectation that your condition will improve materially 
within a reasonable and generally predictable period of time. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial hand prosthesis. 
 
You asked the Plan to pre-approve the requested item. You say that the prosthetic can help you do more. The 
Plan denied your request. The Plan says the prosthesis cannot be covered as requested. 
 
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 L7499 is upper extremity prosthesis, not otherwise 
specified. We find that CPT code L7499 is not supported. There is a more comprehensive code that describes 
the requested prosthetic. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a partial hand prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Consultation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Consultation services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services can be received in-network. 
 
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 
Consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Linzess 145 mcg oral capsule. 
 
You asked the Plan to pre-approve Linzess. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Linzess 145 mcg oral 
capsule.  
 Benefits for Linzess may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 14 Day system. 
 
You asked the Plan to pre-approve the system. You say that the system is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 
 
 We looked at the file and Medicare rules. The documentation does not show that the enrollee is being treated 
with multiple (three or more) daily insulin injections or with a continuous subcutaneous insulin infusion (CSII) 
pump and the documentation does not show the enrollee's insulin treatment requires frequent adjustments based 
on blood glucose monitoring or continuous glucose monitoring testing results. Based on this information, we 
decided that Medicare rules for coverage of the system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the FreeStyle Libre 14 Day system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that services provided 
by an out-of-network provider are not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy provided on July 15, 2021, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from March 5, 2020, 
to March 10, 2020, billed with diagnosis related group (DRG) code 871. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 871. The Plan denied your 
request. The Plan says DRG 871 is not supported as the diagnosis of Sepsis, unspecified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, 
unspecified. 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 inpatient hospital services billed 
with DRG 871. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found 
there is no documentation of persistent hypotension or hemodynamic instability. The patient's platelets, 
creatinine, and total bilirubin all remained within normal limits. Our reviewer found that there is no evidence of 
significant physiologic instability. Our physician reviewer also found that the review has determined that the 
medical records did not support the billing of Sepsis, unspecified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from March 5, 2020, to March 10, 2020, billed with diagnosis 
related group (DRG) code 871.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on July 1, 2021, July 2, 2021, 
July 5, 2021, July 6, 2021, July 7, 2021, July 8, 2021, July 9, 2021, and July 12, 2021, by an OON provider. 
 
You asked the Plan to pay for the therapy services. You say that it was beneficial to provide treatment to the 
enrollee and you would like the claim processed for payment. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the therapy services provided on July 1, 2021, July 
2, 2021, July 5, 2021, July 6, 2021, July 7, 2021, July 8, 2021, July 9, 2021, and July 12, 2021, by an OON 
provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0427) provided 
on October 18, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation. You say that Telehealth Intervention 
Service is a Centers for Medicare & Medicaid Services (CMS) covered service. The Plan denied your request. 
The Plan says medical necessity for ambulance service is established when the patient's condition is such that 
medically necessary services are actually furnished, even if a local government requires an ambulance response 
for all calls. The Plan also says that an ambulance response without transport is to be billed with a "-QL" 
modifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 The ambulance company did not provide transport services on October 18, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that the ambulance arrived, treated the enrollee, and referred them to a Telehealth provider. 
The record does not show that the enrollee was transported by ambulance. Therefore, we decided that the Plan 
does not have to pay for the emergency ambulance transportation (A0427) provided on October 18, 2021.