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

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found evaluating therapists state that enrollee requires intense therapy and would be able to tolerate three (3) 
hours of therapy per day; thus, IRF criteria has been met.  
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: 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 the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in other settings such as a skilled nursing facility, home 
health services or outpatient therapy. 
 
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 enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will decline in health due to a lack of or 
no rehabilitation. The Plan denied your request. The Plan says the records do not show that the enrollee's 
rehabilitation needs are complex and that they need to be seen by a rehabilitation doctor 3 times per week for 
evaluation of functional and medical goals and progress. The services the enrollee needs can be provided safely 
in other settings like a skilled nursing facility (SNF), home with home health services or home with outpatient 
therapy. 
 
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 the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. At minimum level, 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. 
 
Documentation does not support necessity for admission to an IRF. While the enrollee may benefit from 
continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely provided 
in a lower intensity and alternate setting such as in a SNF or in-home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial preventive physical examination service coded 
G0402 and the hospital outpatient clinic visit coded G0463 provided on February 23, 2022. 
 
You asked the Plan to pay for the initial preventive physical examination service and the hospital outpatient 
clinic visit. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0402 and G0463 are not supported in the medical record. Specifically, when a claim 
is reported with multiple medical visits on the same date of service with same revenue code must include 
condition code G0. These services were billed on the same date of service with the same revenue code and 
were not billed with the appropriate condition code. Based on this information, we decided that Medicare rules for coverage of the initial preventive physical examination service and the hospital outpatient clinic visit have 
not been met. Therefore, we decided that the Plan does not have to pay for the initial preventive physical 
examination service coded G0402 and the hospital outpatient clinic visit coded G0463 provided on February 
23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Food and Drug Administration's 
clearance of this procedure means that it is safe and effective. You say that there are 15 peer-reviewed 
publications in 10 different scientific journals supporting the efficacy and safety of basivertebral nerve ablation 
with the Intracept procedure. The Plan denied your request. The Plan says the requested service is considered 
experimental/investigational as it is not widely used and not generally accepted for the suggested use as 
reported in nationally recognized peer-reviewed medical literature. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental and more research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home therapy services provided on August 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is a more 
appropriate code for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional 
services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct 
supervision of auxiliary personnel. Direct supervision in the office setting means the physician must be present 
in the office suite and immediately available and able to provide assistance and direction throughout the time 
the service is performed.  
 
We looked at the file and Medicare rules. The therapy services in question were provided in the home by the 
NPP without supervision. This is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the home therapy services provided on August 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory 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 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 laboratory services provided on March 9, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator billed for dates of service April 
7, 2021, through September 7, 2021. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that medical records supporting the 
medical necessity and proof of delivery were submitted. You say that the claim should be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says proof of delivery was not submitted. 
 
  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 valid proof of delivery. 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 the neuromuscular stimulator billed for dates of service April 7, 2021, through September 7, 2021.
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 the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you 
do not require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intensive therapy. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 while the enrollee may benefit from additional multiple therapies, including 
physical and occupational therapy, the documentation does not reveal that the enrollee requires this therapy on 
an intensive IRF level. 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says enrollee's 
needs can be met 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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 81455 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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the records show that the 
specimen was not collected on the billed date of service. 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 
pay for the laboratory services rendered on April 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2017 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code H2017. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2017 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2017 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code H2017 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2017 billed for date of service March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allergy testing provided on April 7, 2022. 
 
You asked the Plan to pay for the allergy testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous testing will be considered 
medically reasonable and necessary when used to evaluate IgE mediated hypersensitivity to inhalants, foods, 
Hymenoptera, chemicals, and specific drugs. 
 
We looked at the file and Medicare rules. The services rendered are covered for specific evaluation of 
inhalants, foods, Hymenoptera, chemicals, and specific drugs. These services were billed with diagnosis 
K52.29 (other allergic and dietetic gastroenteritis and colitis). The documentation does not support that the 
testing was rendered due to a suspected mediated hypersensitivity to inhalants, foods, Hymenoptera, chemicals, and specific drugs. This means this testing was completed for screening purposes. This testing is not covered 
for screening purposes. Based on this information, we decided that Medicare rules for coverage of the allergy 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the allergy testing 
provided on April 7, 2022.
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have any parental medication; complex wound care or nutrition given via 
a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your 
physical function is at or near your baseline. Although further rehab services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not 
tried and failed the preferred drugs. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our physician reviewer 
found that the enrollee has iron deficiency anemia. The Plan requires a trial of Infed and Venofer before they 
will approve the requested drug. The case file does not contain documentation of trial and failure of the Plans 
preferred drugs. The documentation does not support that the Plans preferred drugs would likely be less 
effective or would likely have adverse effects for the enrollee 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4930 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code A4930. You say that these items were medically necessary. The 
Plan denied your request. The Plan says procedure code A4930 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A4930 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code A4930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4930 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4930 billed for date of service April 26, 2022.