Persius/hicric huggingface dataset:
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 are appealing based on the enrollee's history of 
present illness, functional deficits, and rationale for admission to acute rehabilitation to facilitate return to home 
and community. The Plan denied your request. The Plan says the information provided lacks the medical 
complexity and the enrollee's therapy needs are at a minor level and can be handled at a lower level of 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 that on review of the available records, the enrollee with cervical spinal stenosis with 
mild myelopathy as described above, does not meet CMS coverage criteria for IRF admission. 
 
The enrollee is medically stable and does not need physical medicine and rehabilitation physician's supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. No acute rehabilitation nursing needs identified or documented. At the current functional 
status, 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. 
 
IRF admission is not medically necessary based on lack of medical complexity and acute rehabilitation nursing 
needs and current functional status (minimum for mobility). Documentation does not support the medical 
necessity for admission to an IRF. 
 
While the enrollee may benefit from continued physical therapy and Occupational therapy, their 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oxygen concentrator and portable oxygen. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that home oxygen is covered when specific criteria 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has severe combined 
obstructive and restrictive lung disease with pulmonary hypertension. Exercise hypoxemia with oxygen 
saturation (SpO2) at 73 percent was demonstrated in 2021, and since then the enrollee has undergone thoracic 
surgery with complications, so her pulmonary status has not improved. The continued home oxygen is 
reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve an oxygen concentrator and portable oxygen.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on May 10, 2021. 
 
You asked the Plan to pay for the services provided. You say that it is necessary for the doctor to discuss the 
results at your appointment. The Plan denied your request. The Plan says that the labs were not medically 
necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services provided by a contract provider. The file does not show that the Plan 
provided notice that the services would not be covered. Under Medicare rules, this means the services are 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on May 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested oxygen is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
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 an oxygen concentrator. Our reviewer 
says that the documentation does not support that the requested oxygen is medically reasonable or necessary. 
Our physician reviewer found you have chronic obstructive pulmonary disease (COPD). The documentation 
does not support that you meet coverage requirements. Your oxygen saturation at rest was 89%. Your oxygen 
need is 88% or less. Therefore, you do not meet criteria for the requested oxygen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skye Wound BioSkin flow (Q4162) provided on October 28, 
2021. 
 
You asked the Plan to pay for Skye Wound BioSkin flow. You say that this procedure was medically necessary 
for the enrollee. The Plan denied your request. The Plan says the procedure was considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for Skye Wound BioSkin flow. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 72-year-old with a chronic non-healing venous ulceration of the left 
lateral leg. The enrollee then underwent treatment with Sky wound flow. The clinical value and effectiveness 
of Skye Wound flow in the setting of venous insufficiency wound have not been demonstrated in the peer 
reviewed literature. The review has determined that the items/services at issue in this case were 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 Skye Wound BioSkin flow have not been met. Therefore, we decided that the 
Plan does not have to pay for Skye Wound BioSkin flow (Q4162) provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the facet joint injections (64490, 64491). 
 
You asked the Plan to pre-approve the facet joint injections. You say that this service is medically necessary. 
The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that injections are covered for pain that has been present 
for a minimum of 3 months with documented failure to respond to noninvasive conservative care, if tolerated. 
 
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 injections. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the patient was unable to tolerate 
physical therapy. If the patient cannot tolerate continued therapy, then there is no requirement to continue. The 
injections are 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 the facet joint injections have been met. Therefore, we decided that the Plan has 
to pre-approve the facet joint injections (64490, 64491).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray (71046) provided on February 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that this service was medically necessary. The Plan denied 
your request. The Plan says out-of-network care is only covered in certain limited circumstances. The requested 
services were not urgent or emergent, nor were they pre-approved. This x-ray could have been performed by a 
plan provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 x-ray (71046) provided on February 8, 2022, 
by an out-of-network (OON) provider.
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 cannot go to lower level of 
care due to current respiratory status. The Plan denied your request. The Plan says based on Medicare 
guidelines, the requested LTACH services do not meet the requirements for approval. 
 
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 that 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 setting. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only 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 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 a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that the admission is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not require daily skilled services. 
 
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 admission. Our reviewer says that 
the enrollee did not meet the Medicare criteria for SNF care. 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. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
She has tried physical and chiropractic therapy as well as ice, heat, non-steroidal anti-inflammatory drugs 
(NSAIDs) and muscle relaxants. The imaging shows degenerative disc disease and ab road-based bulge without 
foraminal stenosis. The request does not meet the Medicare criteria in that imaging does not correlate to a pain 
generator of radicular pain. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology procedure (G0452) provided January 7, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that medical records documenting all billed units 
are attached, providing evidence of their medical necessity. Please review and reprocess for payment. The Plan 
denied your request. The Plan says this is a duplicate claim/original claim in process. 
 
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 G0452 is molecular pathology procedure; physician 
interpretation and report. 
 
We find that CPT code G0452 is not supported in the medical record. Specifically, this claim was processed on 
January 17, 2022. Based on this information, we decided that Medicare rules for coverage of the laboratory 
service have not been met. Therefore, we decided that the Plan does not have to pay for molecular pathology 
procedure (G0452) provided January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (92014) provided on March 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that it was the facility's responsibility to 
obtain prior authorization The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
  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 ophthalmological services (92014) provided 
on March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on February 6, 2022. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the 
ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance 
transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, non-
emergency transport. Our reviewer says that ambulance service, basic life support, non-emergency transport 
was not medically necessary. Our physician reviewer found that the documentation does not support that other 
means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this enrollee. There is no documentation that one of these other means of transport would 
have been contraindicated. The documentation does not support that the enrollee needed the expertise, services 
and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The enrollee was transported to a private home after hospital discharge. There was no need for BLS 
or ALS monitoring or intervention. The documentation does not support that the ambulance transport was 
medically reasonable and necessary for 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 ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport provided on February 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services (99496) billed for date 
of service January 10, 2022. 
 
You asked the Plan to pay for transitional care management services. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 99496 is not supported in the case record. Specifically, no records have been provided 
for services rendered on January 10, 2022. Based on this information, we decided that Medicare rules for 
coverage of transitional care management services have not been met. Therefore, we decided that the Plan does 
not have to pay for transitional care management services (99496) billed for date of service January 10, 2022.