Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (83789) provided on October 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service 
 
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 83789 
is a column II code to column I code G0480. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (83789) provided on 
October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen treatment (G0277) provided on May 3, 
2021. 
 
You asked the Plan to pay for hyperbaric oxygen treatment. You say that it takes 30 additional minutes to go 
down and back up. The Plan denied your request. The Plan says only 3 units of this code are supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 4 units of CPT code G0277 are not supported in the medical record. The medical record only 
supports 3 units of CPT code G0277. Each unit represents 30 minutes, and the records document a total time of 
90 minutes. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen 
treatment have not been met. Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen 
treatment (G0277) provided on May 3, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has 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 that the requested admission to a SNF is not medically 
necessary. 
 
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 you 
meet the Medicare criteria for SNF care. Our physician reviewer found you do not have documented skilled 
nursing needs. You do have documented skilled therapy needs. Daily skilled services are required to establish a 
maintenance program and/or to prevent deterioration of your condition. 
 
 
  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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity 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 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 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 the 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia for upper gastrointestinal endoscopic procedures (00731) 
provided on September 29, 2021. 
 
You asked the Plan to pay for the anesthesia for upper gastrointestinal endoscopic procedures. You say that you 
would like this claim reprocessed. The Plan denied your request. The Plan says that the place of service billed 
is inconsistent with the patient being in a registered inpatient status. 
 
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. In this case, the Plan has denied coverage based on the point of service code 
billed with this claim. A copy of the claim form was not included in the documentation we received. Without 
this documentation, we cannot confirm the Plans argument of an incorrect point of service being billed. 
Therefore, we decided that the Plan has to pay for the anesthesia for upper gastrointestinal endoscopic 
procedures (00731) provided on September 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block procedures (64490, 64491). 
 
You asked the Plan to pre-approve medial branch blocks. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request exceeds Medicare 
limitations. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are covered only when 
they are 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 medial branch blocks.  Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the request exceeds utilization criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch block procedures (64490, 64491).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. 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. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
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 you do not require skilled nursing services. It 
is not medically reasonable and necessary to provide skilled services on a daily basis. As a practical matter, you 
do not require the necessary services on 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred agents would likely be less effective, and/or 
cause adverse effects for you. 
 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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary. The Plan requires a trial of Durolane, Monovisc or Synvisc-
One before they will approve the requested drug. In this case, you have not tried and failed the required drugs. 
There is no documentation provided indicating that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step 
therapy criteria for Gel-One. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial strain imaging services. 
 
You asked the Plan to pre-approve myocardial strain imaging services. You say that  The Plan denied your 
request. The Plan says they do not have clinical records showing that the indications for coverage apply to the 
enrollee in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of myocardial strain imaging services. 
have been met. There were no medical records submitted. The case file shows evidence of the Plan having 
made reasonable attempts to obtain this necessary documentation. Without medical records, we are unable to 
determine whether the requested test is medically reasonable and necessary. Therefore, we decided that the 
Plan does not have to pre-approve myocardial strain imaging services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant-at-surgery services during a joint replacement 
provided on July 28, 2020. 
 
You asked the Plan to pay for the surgical assistant services. You say that you feel that there is no reason that 
payment should not be made for these services as you were acting within the scope of your license. The Plan 
denied your request. The Plan says this type of provider is not eligible to bill Medicare for surgical assistant 
services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 
 A review of the state licensure databases and the file do not show that the provider of the surgical assistant 
service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when 
provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the 
assistant-at-surgery services during a joint replacement provided on July 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal photopheresis (36522) provided on October 
20, 2021. 
 
You asked the Plan to pay for extracorporeal photopheresis. You say that this treatment was medically 
necessary. The Plan denied your request. The Plan says this treatment is not covered by Medicare.  
The Plan follows Medicare rules. Medicare rules say that extracorporeal photopheresis is reasonable and 
necessary under specific circumstances. 
 
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 extracorporeal photopheresis. Our reviewer 
says that the requested treatment is not medically necessary. Our physician reviewer found the enrollee has 
been on apheresis treatment since 2018 which has resulted in ending supplemental oxygen and hospitalizations. 
Therefore, the reviewer found that the requested extracorporeal photopheresis treatment does not meet the 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracorporeal photopheresis have not been met. Therefore, we decided that the 
Plan does not have to pay for extracorporeal photopheresis (36522) provided on October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested inpatient psychiatric 
care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity 
rules for coverage for inpatient psychiatric care have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric care is not medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is not shown to be a danger to self or others but is without agitation 
or aggression without perceptual disturbance including auditory or visual hallucinations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have 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 you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stent placement (36010, 37238, 37239, 37252, 75822, 
75825, 76937, 99152, J1170, J3010, J3360) provided September 14, 2021. 
 
You asked the Plan to pay for the stent placement. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim is a duplicate and cannot be paid. 
 
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 36010, 37238, 37239, 37252, 75822, 75825, 76937, 99152, J1170, J3010, & J3360 are 
not supported in the medical record. Specifically, only one unit of each code is supported. The claim is a 
duplicate and the report provided are duplicates. Based on this information, we decided that Medicare rules for 
coverage of the stent placement have not been met. Therefore, we decided that the Plan does not have to pay 
for a stent placement (36010, 37238, 37239, 37252, 75822, 75825, 76937, 99152, J1170, J3010, J3360) 
provided September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (83789) provided on September 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 83789 
is a column II code to column I code G0480. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (83789) provided on 
September 30, 2021.