Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you feel these services are needed for 
your care. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care, and 
you do not require transfer to an LTACH. 
 
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 you appear to be more stable and improving and should only require short-term 
additional acute care services that can safely be administered at the current facility. Transfer to the LTACH 
would not be clinically advantageous at this time and completion of treatment at the current facility is 
recommended. 
 
 
 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right lower extremity stab phlebectomy services. 
 
You asked the Plan to pre-approve right lower extremity stab phlebectomy services. You say that the 
phlebectomy is medically necessary to treat the varicose veins and should be a covered plan benefit. You say 
that the enrollee has worn compression stockings for many years. The Plan denied your request. The Plan says 
the enrollee does not meet Medicare guidelines for coverage of the requested treatment. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins are covered when 
medically necessary and for certain clinical indications.  
 
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 right lower extremity stab phlebectomy 
services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee has saphenous reflux which has not yet been treated. For phlebectomy to be covered, there needs to be 
a demonstration that the enrollee remained significantly symptomatic when evaluated at least 6 weeks 
following treatment of saphenous reflux that persists despite continued conservative treatment. In addition, the 
documentation describes the tributary veins to be less than 4 mm in diameter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right lower extremity stab phlebectomy services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve right lower extremity stab phlebectomy 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 skilled services are necessary and appropriate 
for the enrollee's medical needs. The Plan denied your request. The Plan says the Medicare guidelines for SNF 
admission were not met and the enrollee can receive the services they need at a long-term care facility. 
 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 that there are no identifiable skilled nursing service needs and there are no 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. This enrollee does not meet severity of illness or intensity of service criteria for 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on March 
2, 2022. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
POS code to be used by the physician or other supplier will be assigned as the same setting in which the 
beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. In this case, the enrollee was in a Part A covered stay, which means 
that POS code 31 should be used. Based on this information, we decided that Medicare rules for coverage of 
the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled 
nursing facility (SNF) services provided on March 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the request 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 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee could benefit from physical 
therapy and occupational therapy that can be provided in LTACH. The Plan denied your request. The Plan says 
an LTACH is not medically necessary. and the enrollees current needs can be met in the current setting. 
 
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 or the skilled nursing facility and can receive a lower level of care when deemed appropriate. 
 
   
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 LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on March 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Medicare does not pay for these services separately. 
 
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. The plan has given very little information as to why these services were denied. 
They say "Medicare does not pay for these services separately" but doesn't specify what coding or benefit 
guidelines were used for this denial. The denial cannot be verified with the lack of information in the case file. 
Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on March 15, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronic acid knee injections for knee pain.  
You asked the Plan to pre-approve Hyaluronic acid knee injections. You say that you feel the enrollee would 
benefit from having these injections in both knees. The Plan denied your request. The Plan says Hyaluronic 
acid knee injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that intra-articular injections of other therapeutic agents, 
such as corticosteroids, should not be performed in the same knee during the course of viscosupplementation 
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 Hyaluronic acid knee injections. Our 
reviewer says that the enrollee does not meet the criteria for coverage for the Hyaluronic acid knee injections. 
Our physician reviewer found there is no documentation that the enrollee meets all of the conditions indicated 
for coverage that are listed in the Local Coverage Determination (LCD) for Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427). Our reviewer also found that the provided records document the 
hyaluronic acid knee injections are to be given with a steroid injection at the same time which is not advised by 
the LCD or the Medicare-approved major drug compendia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronic acid knee injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Hyaluronic acid knee injections for knee pain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223.  
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service February 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 18, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says this was not reported correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 18, 2021 billed with codes 81206 and 81292.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that you have family members with 
Alzheimer's, and have taken cognitive testing and had a magnetic resonance imaging. You also say that you 
failed most of the testing and your doctor wants more information to make an informed proper diagnosis. The 
Plan denied your request. The Plan says there is no documentation that you have findings consistent with FTD 
(frontotemporal dementia) or are part of a clinical trial. The Plan also says that Medicare only covers PET 
studies for these indications. 
 
The Plan must follow Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD.  
 
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 PET scan of the brain. Our reviewer 
says that you do not meet CMS requirements for a PET scan. Our physician reviewer found CMS does not 
cover PET scans unless there is a clinical differential diagnosis of Alzheimer's dementia versus FTD 
(frontotemporal dementia). Our reviewer also found that no behavioral changes are described in the records to 
bring to mind possible FTD. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (3BC11, G0151, G0152, G0157, 
G0300, G0495, Q5001) provided on April 28, 2022, to May 26, 2022. 
 
You asked the Plan to pay for the home health services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 3BC11, G0151, G0152, G0157, G0300, G0495, & Q5001 are not supported in the 
medical record. Specifically, the Notice of Admission was submitted with an invalid type of bill. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services (3BC11, G0151, G0152, 
G0157, G0300, G0495, Q5001) provided on April 28, 2022, to May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code 97110. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526. 
 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 97110 
is a column II code to column I code 92526. 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 97110 billed for date of service March 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service February 18, 
2022. 
 
You asked the Plan to pay for procedure code 97110. The Plan denied your request. The Plan says payment for 
code 97110 is bundled into payment for code 92526.  
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 97110 
is a column II code to column I code 92526. 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 97110 billed for date of service February 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of 
computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing (76377) provided on February 15, 2022. 
 
You asked the Plan to pay for procedure code 76377. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 76376 and 76377 must be performed in 
conjunction with the base imaging procedure. 
 
The documentation does not support that this code was billed with a base imaging procedure. Therefore, we 
decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing (76377) provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), but there are no 
pulmonary function tests for confirmation. There is no arterial blood gases (ABG) done while stable as an 
outpatient to confirm chronic carbon dioxide (CO2) retention, but if this is confirmed, the enrollee may benefit 
from bilevel positive airway pressure (BiPAP) during sleep. Overnight oximetry in the hospital while the enrollee was on BiPAP 20/10 and 30% O2 showed no significant desaturations.  Medicare does not cover a 
home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says LTACH care is not medically necessary and that 
continued acute hospital care is appropriate until the enrollee can discharge to a lower level of care. 
 
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 was admitted with lower extremity cellulitis and ulcer in the setting of 
calciphylaxis that failed out-patient therapy. The record indicates that the enrollee is improving but still require 
acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care 
services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that she is not currently receiving but that would be available at the LTACH 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.