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. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided you appear to not be stable enough for transfer 
at this time. Acute care services can be safely administered at the current facility for the time being until 
treatment is completed and transfer to a lower level of care is more appropriate. You do not require services at 
the LTACH that are not already available at the current facility. There are no services at the LTACH that you 
require that are not already available and covered at the current 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.
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 care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 patient is a 76-year-old female who was admitted to the acute care hospital with 
acute respiratory failure, pneumonia, sepsis, diabetic ketoacidosis complicated by encephalopathy, 
cholecystitis, and acute kidney injury. The patient requires additional care for infection and is stabilizing. The 
patient appears to be somewhat unstable still but improving and should only require short-term additional acute 
care services to further stabilize that can safely be administered at the current facility. The patient does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be advantageous. Transfer may be considered when 
treatment has completed and the patient is more stable. 
 
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: Favorable

 
We decided that the Plan has to pay for the transversus abdominis plane (TAP) blocks (64488) provided on 
September 10, 2021. 
 
You asked the Plan to pay for the TAP blocks (64488). You say that studies show the benefit of bilateral TAP 
blocks combined with Rectus blocks gives superior results for laparotomy and laparoscopic surgery. You say 
that this code was billed properly for multiple injections sites and is eligible for reimbursement for each CPT 
code. The Plan denied your request. The Plan says that the information provided does not support the frequency 
of service. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service. The rules state that modifiers XE, XS, 
XP, XU were developed to provide greater reporting specificity in situations where modifier 59 was previously 
reported and may be used in lieu of modifier 59. 
 
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 TAP blocks (64488) Our reviewer says 
that the billing of CPT code 64488-59 and 64488-XU is correct. Our physician reviewer found that the enrollee 
has a body mass index of 55 and received a TAP block for post-operative pain relief. The procedure is 
ultrasound guided and can be very difficult due to the body habitus of the enrollee. This is a separate service 
from the anesthetic and is aimed at avoiding giving opiates that may cause serious complications. 
 
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 TAP blocks (64488) have been met. Therefore, we decided that the Plan has 
to pay for the transversus abdominis plane (TAP) blocks (64488) provided on September 10, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
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 patient is a 69-year-old female who was admitted to the acute care hospital 
with acute respiratory failure, non-ST-elevation myocardial infarction (NSTEMI), and complicated by multiple 
cerebrovascular accidents. Recent notes describe the patient as having new infection of surgical wounds 
requiring ongoing intravenous antibiotics and monitoring. The patient appears to be somewhat unstable still 
and should only require short-term additional acute care services to care for her infection and perform weaning 
attempts that can safely be administered at the current facility until more stable. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is 
not medically necessary as it would not be advantageous. Transfer may be considered when treatment has 
completed and the patient is more stable. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve a SI injection. You did not provide an argument for coverage with your 
appeal request. The Plan denied your request. The Plan says that this service is not medically necessary because 
the records do not show that the first injection reduced the patient's pain significantly. 
 
The Plan follows Medicare rules. Medicare rules say that SI joint injections are covered for the treatment of 
chronic low back pain when medically necessary and when previous injections have shown immediate and the 
potential for long-lasting pain relief. 
 
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 SI injection. Our reviewer says that 
the requested SI joint injection is medically necessary. Our physician reviewer found this request meets to 
coverage criteria listed in the Medicare rules and is reasonable and necessary for the treatment of the patient's 
condition. The patient has sacroiliitis and is on numerous medications.  She had a right SI join injection which 
gave her 98% pain relief 6 weeks later and was able to complete her activities of daily living with less 
difficulty. 
 
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 SI injection have been met. Therefore, we decided that the Plan has to pre-
approve a sacroiliac (SI) joint injection.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had 
stable vital signs. The enrollee was at a minimal to moderate assist level for functional mobility including gait 
to 80 feet with a rolling walker. The enrollee does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radionuclide stress testing. 
 
You asked the Plan to pre-approve radionuclide stress testing. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the enrollee's coverage has terminated, and this will not be 
covered. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is subject to the 
criteria listed 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 radionuclide stress testing. Our 
reviewer says that the requested radionuclide stress testing is not medically reasonable and necessary. Our 
physician reviewer found 69-year-old woman with history of atypical chest pains with a normal 
electrocardiogram (ECG), practitioner now requesting authorization for radionuclide stress testing. At issue is 
the appropriateness and medical necessity of performing a radionuclide stress test in this patient.  Patient has an 
interpretable ECG.  As such, as per current guidelines, there is no evidence to support the requested 
radionuclide stress testing in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radionuclide stress testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radionuclide stress testing.
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 the enrollee is a 73 -year-old male who was hospitalized on April 10, 2022, with decline in function. Based on review of available records, the enrollee with chemotherapy related 
encephalopathy and debility does not meet coverage criteria for an IRF admission. At the current medical 
status, there is no need for a physical medicine and rehabilitation physician to oversee the enrollees care three 
times per week for the ongoing management of active or chronic medical conditions. No acute skilled nursing 
needs documented. Based on the above functional status, the enrollee does not need IRF level of therapies, 3 
hours a day for 5 days a week with multidisciplinary approach. Documentation does not support the need for 
therapies at an IRF level with interdisciplinary approach. Medical records do not support the necessity for an 
IRF admission. 
 
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: 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 the clinical information provided supports the need 
for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke and was discharged home on February 23, 2022. The enrollee's medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: 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 this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 74-year-old female being treated for spondylosis without 
myelopathy or radiculopathy, lumbar region; vertebrogenic low back pain, low back pain, vertebral endplate 
pain. She presented with lower back pain that has been unchanged. She has left leg pain (that has not changed) 
to the hip/buttock area. The pain is currently 5/10 and is mainly to the left bursitis area. The pain is worse with 
prolonged sit or stand and walking for distances. The pain is improved with stretching, heat, and exercises. She 
feels that her left leg is weak. Height is 67 inches, weight 209 pounds, and body mass index of 32.73 kg/m2. 
An exam reveals left and right iliolumbar tenderness. Facet loading is positive bilaterally. She has an antalgic gait and uses a cane on her right hand. Tenderness to palpation is noted on the left greater trochanteric bursa 
and sacroiliac joint area. Light touch sensation is diminished in the feet. 
 
In this case, there were/are multiple plausible pathologic sources of significant pain generation. Overall, 
documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time.  Therefore, the request for Intracept intraosseous nerve 
ablation at L5 and S1 is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 the patient was admitted for congestive heart failure and coronary artery bypass 
grafting. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) scan of the 
abdomen and pelvis. 
 
You asked the Plan to pre-approve MRI of the abdomen and pelvis. You say that this is medically reasonable 
and necessary. The Plan denied your request. The Plan says they did not make a decision in time on this case. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the abdomen and pelvis. Our 
reviewer says that the requested imaging service is not medically reasonable and necessary. Our physician 
reviewer found that the enrollee has chronic abdominal pain and constipation. Her lab data and available 
kidney, ureter, and bladder (KUB) X-rays do not support bowel obstruction, concern for active bowel 
inflammation, and there is no history of bowel ischemia. Her provided examination on the whole is inconsistent 
with an "acute surgical abdomen. MRI for enterography and/or defecography is premature in the absence of 
results of colonoscopic findings, manometric data, and gastrointestinal transit imaging.  As such, medical 
necessity criteria are not met at this time for MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the magnetic resonance imaging (MRI) scan of the abdomen and pelvis.