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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility (IRF). 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. 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 the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance for needle placement used during 
trigger point injections from March 12, 2021, through May 7, 2021. 
 
You asked the Plan to pay for the ultrasound guidance used with trigger point injections. You say that the use 
of ultrasound guidance should be paid as it was medically necessary. The Plan denied your request. The Plan 
says the use of ultrasound guidance for trigger point injections is not shown to improve outcomes. As such, it is 
not considered reasonable and necessary. 
 
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 pay for the ultrasound guidance used with trigger 
point injections. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic back pain for which trigger point 
injections were performed. The trigger points were identified by palpation. Description of the ultrasound 
guidance does not list the actual muscle injected. Since the trigger points were palpated, the use of ultrasound 
for guidance was not 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 ultrasound guidance used with trigger point injections have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound guidance for needle placement used 
during trigger point injections from March 12, 2021, through May 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from December 11, 2021, 
through December 27, 2021. 
 
  You asked the Plan to pay for the physical therapy services. You say that the provider said you needed more 
physical therapy and suggested you continue with the physical therapy. You also say that you were not aware 
that the prior authorization only allowed 10 visits, and the services should be covered. The Plan denied your 
request. The Plan says the provided medical records did not provide adequate documentation to support the 
medical necessity of additional physical therapy services provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay the physical therapy visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there is no documentation of a recent injury or decline in function. 
You have previously been treated with outpatient therapies and should be independent with a home exercise 
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 the physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided from December 11, 2021, through December 
27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic injection to the brachial plexus and the related 
ultrasound guidance provided on July 16, 2020, billed with codes 64415 and 76942. 
 
You asked the Plan to pay for the injection with ultrasound guidance. You say that this was not part of the 
anesthesia and should be separately paid. This injection was done for postoperative pain management. The Plan 
denied your request. The Plan says the records do not support that a postoperative nerve block was performed. 
 
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 64415 is injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus. 
 
We find that CPT code 64415 is not supported in the medical record. Specifically, the records provided do not 
include documentation of a postoperative injection to the brachial plexus. Since the injection is not 
documented, the guidance for needle placement coded as 76942 is also not covered. Based on this information, we decided that Medicare rules for coverage of the injection with ultrasound guidance have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthetic injection to the brachial plexus and 
the related ultrasound guidance provided on July 16, 2020, billed with codes 64415 and 76942.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. She can continue to receive custodial 
care at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99310) provided on 
November 19, 2021. 
 
You asked the Plan to pay for nursing facility care. You say that this claim was billed correctly with Place of 
Service (POS) code 31. The Plan denied your request. The Plan says this service was billed with an 
inappropriate POS code. Code 32 is more appropriate for the facility in this case. The Plan also states that they 
reached out to the facility directly and confirmed that the appropriate POS code in this case is 32. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. POS code 31 describes a facility which 
primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, 
or rehabilitative services but does not provide the level of care or treatment available in a hospital. POS code 
32 describes a facility which primarily provides to residents skilled nursing care and related services for the 
rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the 
level of custodial care to other than individuals with intellectual disabilities. 
 
We find that CPT code 99310 is not supported in the medical record as billed with POS 31. Specifically, the 
facility in this case is a long-term nursing facility which is better described with code 32. Based on this information, we decided that Medicare rules for coverage of nursing facility care have not been met. A 
corrected claim may be submitted directly to the Plan. Therefore, we decided that the Plan does not have to pay 
for subsequent nursing facility care (99310) provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on October 5, 
2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the service 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. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the record. Specifically, the documentation does not support 
the presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (99152) provided on October 5, 2021.
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. The Plan denied your request. The Plan says the IRF services you 
are requesting do not meet the requirements for approval. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the services. You say that you are a fall risk and need assistance walking. 
The Plan denied your request. The Plan says your condition is back at baseline. 
 
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 the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. 
You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to 
be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs 
are custodial and intermittent. They can, as a practical matter, be provided at a lower level of care, such as 
assisted living and long term 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam, and 
you should not owe a copayment. The Plan denied your request. The Plan says this eye exam was provided for 
evaluation and treatment of diabetic retinopathy, for which you already had a diagnosis. That means that this is 
a medical eye exam, and the $35 copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.  
 You have been asked to pay a $35 copayment for the eye exam. The eye exam was provided for a medical 
condition in this case, and therefore falls within the Medicare-covered exams to diagnose and treat diseases and 
conditions of the eye benefit category. Please note that a routine eye exam is provided to detect changes in the 
eye for eyeglasses/contacts and is not provided for medical purposes. A screening is provided for those who do 
not have symptoms or signs of a disease, but it may be necessary to check anyway to make sure any issues are 
caught early. If you are already diagnosed with a disease (such as diabetic retinopathy) or had symptoms which 
required examination, this would be a medical exam and not a screening. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the eye exam (92014) provided on December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with multiple 
accessories and power options for the enrollee. 
 
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 request exceeds the enrollee's needs for mobility and positioning. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have a neurologic disorder that is causing her mobility impairment. She is able to assist in her own transfers 
and there is no indication that she has significant edema that would require power leg rests. She does not 
require power tilt or recline as she can redistribute her own weight. The requested power wheelchair - group 2 - 
is 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 a group 2 standard power wheelchair with multiple accessories and power options for the 
enrollee.
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 services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 
services are medically necessary. Our physician reviewer found based on the limited documentation provided, 
the enrollee does qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The 
enrollee does have documented skilled therapy needs. The enrollee is not yet walking household distances or 
shown to be able to navigate stairs. Daily skilled services are required to establish a maintenance program 
and/or to prevent deterioration of the enrollees 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 25, 
2021. 
 
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 Healthcare Common Procedure Coding System (HCPCS) Code G0483 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on May 25, 2021.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says that the 
enrollee's needs can be met at an alternate level of care that is less intensive. 
 
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 medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no rehabilitation nursing needs identified 
or documented in the record. At the current functional 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 to 
daily therapy in an IRF. An IRF admission is not medically necessary based on medical stability, lack of 
medical complexity, lack of rehabilitation nursing needs, and current high level of functional mobility. The 
documentation does not support the necessity for admission to an IRF. While the enrollee may benefit from 
physical therapy and occupational therapy, the enrollee's rehabilitation can be safely provided at a lower 
intensity and alternate setting such as in an SNF or 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 acute inpatient rehabilitation facility (IRF) admission and services.