Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says when the 
enrollee is ready to leave the hospital, the enrollee can safely receive this care in another setting, such as a 
Skilled Nursing Facility (SNF) or at home with home health services or outpatient 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that genicular nerve ablation is medically 
necessary. The Plan denied your request. The Plan says genicular nerve ablation is 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 pre-approve genicular nerve ablation. Our reviewer 
says that the requested genicular nerve ablation is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that genicular nerve ablation is the subject of ongoing clinical trials. It is 
considered experimental/investigational. Therefore, the request is deemed not medically reasonable and 
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 genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
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 have no one to help take care of you at home. 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant. 
 
You asked the Plan to pre-approve injection of sclerosant. 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 follows Medicare rules. Medicare rules say that Invasive procedures for the treatment of varicose 
veins are considered medically reasonable and necessary 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 injection of sclerosant. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the documentation does not 
meet coverage criteria and does not support the medical necessity of the procedure in question. Coverage 
criteria require that the enrollee's symptoms be due to the veins to be treated. In this case the enrollee does not 
have venous reflux documented and does not have edema but does have significant peripheral artery disease. 
The recent patient assessments do not include an ankle brachial index (ABI) or pulse examination. The 
description of the enrollee's symptoms is also inadequately detailed on which to support coverage of a medical 
procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection of sclerosant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection of sclerosant.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rebif Rebidose. 
 
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 self-administered drugs are not covered. 
 
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 Rebif Rebidose.  
 
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightwheight wheelchair (K0005) and related 
accessories. 
 
You asked the Plan to pre-approve a lightwheight wheelchair and related accessories. You say that the items 
are medically necessary. The Plan denied your request. The Plan says there is no other documentation 
regarding details of this members current wheelchair or if there have been attempts to repair or modify this 
member current wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a wheelchair. a wheelchair serves the same purpose as a lightwheight wheelchair 
and related accessories. Therefore, we decided that the Plan does not have to pre-approve a lightwheight 
wheelchair (K0005) and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 office visit to be provided 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 LTACH is the safest and most efficient 
care level for appropriate wound assessment and treatment. 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 in this case the documentation does not support that the enrollee has need for 
complex medical treatment in a LTACH.  The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility. The requested treatments are not medically 
necessary at the LTACH level of care. The enrollee has improved medically but continues to require treatment 
in an acute care hospital. The enrollee can receive further care at the current acute care hospital or 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 13, 2022 to 
July 15, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that you were not informed that the provider did not 
accept Medicare and was not participating with the Plan. The Plan denied your request. The Plan says this 
provider is not eligible to receive payment for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from January 13, 2022 to 
July 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99213 billed for date of service August 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that a modifier 79 was submitted. The Plan denied 
your request. The Plan says that the code is included in the global surgery period without an appropriate 
modifier. 
 
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. 
 
We looked at the file and the rules. The Plan denied code 99213 as included in the payment for code 28285. 
The case file does not include documentation, such as a claim or explanation of benefits (EOB), for code 28285 
to confirm whether or not the code at issue would be included in the global surgery period. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for procedure code 99213 billed for date of 
service August 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intra-dialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN. You say that there is no in-network provider than can offer IDPN 
therapy. The Plan denied your request. The Plan says the enrollee does not meet criteria for parenteral nutrition. 
 
The Plan must follow Medicare rules. Medicare rules say that parenteral nutrition is only covered if enteral 
nutrition has been tried and ruled out, found ineffective, or exacerbates dysfunction. The enrollee must have a 
permanent impairment. The enrollee must have: 
a. A condition involving the small intestine and/or its exocrine glands which significantly impairs the 
absorption of nutrients 
b. Disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients 
to be transported through and absorbed by the gastrointestinal (GI) system. 
 
We looked at the file and Medicare rules. The record does not show that enteral nutrition has been tried and 
ruled out, found ineffective, or found to exacerbate the enrollees dysfunction. Based on this information, we 
decided that Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intra-dialytic parenteral nutrition (IDPN).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 26, 
2021, to August 27, 2021. 
 
  You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
there was no documentation of complications related to an ambulatory surgical procedure, complex 
postoperative course, or need for treatment that could not be appropriately provided in an ambulatory setting. 
The Plan also says evaluation, treatment, and monitoring in a lower level of care, such as observation, may 
have been an option. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee presented to the emergency department with left groin pain 
related to longstanding mass/swelling in left groin and scrotum. Workup and examination revealed incarcerated 
left inguinal hernia, and vitals were stable. Our reviewer found that the enrollee underwent left inguinal hernia 
repair without complication. Vitals remained stable following the procedure. He was discharged home the same 
day. Our physician reviewer also found that it was not expected that the enrollee would require hospital 
services that would likely cross 2 midnights based on the low complexity and low severity of the presentation. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from August 26, 2021, to August 
27, 2021.
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 is medically stable to be 
transferred to an LTACH. You say that the enrollee's needs an LTACH to continue aggressive pulmonary 
toileting. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and 
the enrollee can safely receive the care they need in another 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. The enrollee has improved medically and can receive a lower 
level of care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on April 12, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code was 
billed during a covered Part A stay. 
 
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 A6222 is gauze, impregnated with other than water, 
normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. We find 
that CPT code A6222 is not separately payable. The payment for services is included in the payment to the 
skilled nursing facility the enrollee was in at the time of service. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the supplies provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service August 12, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the doctor did not bill this code before. The Plan 
denied your request. The Plan says an inappropriate place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient. 
 
 We find that CPT code 99223 was billed with an inpatient place of service code. The enrollees claim 
information shows that the enrollee was an outpatient on the date of service at issue. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99223 billed for date of service August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (SIJ). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is considered experimental, investigational, and unproven. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the 
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and 
investigational.  Studies completed say that this procedure does not improve outcomes compared to standard 
treatment of SIJ pain.  Radiofrequency ablation for denervation, whether performed using traditional, cooled, 
or pulsed radiofrequency, is considered investigational and therefore, not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation of the sacroiliac joint (SIJ).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for kerecis omega3, per square centimeter provided to the 
enrollee on September 22, 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 the documentation submitted does not support the billing of four units. 
 
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 Q4158 is "Kerecis omega3, per square centimeter." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the record states that 3 sq cm 
were used on the date of service in question. This supports that three units were rendered, not four. 
 
We looked at this coder's review, the file, and Medicare rules. 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 kerecis omega3, per square centimeter provided to the enrollee on September 22, 2022.