Persius/hicric huggingface dataset:
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 the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the health plan has argued that the enrollee did not require SNF level care because 
the enrollee was functioning at her baseline. The health plan has provided no records to show what the 
enrollees baseline was. As such, the health plan has failed to support its argument. 
 
   
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 the drug testing services provided on March 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says lab 
services must be performed by a contracted laboratory. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the drug testing services provided on March 15, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the guidelines and the clinical 
documentation included with the appeal supports the requested service. The Plan denied your request. The Plan 
says the request is not medically necessary, the services the enrollee needs can be provided safely 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. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine intravenous (IV) infusions. 
 
You asked the Plan to pre-approve Ketamine infusions. You say that it feels like you are getting beat by metal 
bats. You also say that Ketamine infusions help with that greatly. The Plan denied your request. The Plan says 
the requested drug is not approved by the FDA for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ketamine infusions. Our reviewer says 
that Ketamine infusions are not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
reviewer found that the Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested Ketamine 
infusions are 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 Ketamine infusions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ketamine intravenous (IV) infusions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature (L5981, 
L5986). 
 
You asked the Plan to pre-approve a prosthetic leg with an advanced foot feature. You say that the enrollee was 
walking without any assistive devices even with foot wounds and special foot wound footwear before 
amputation. Her current assistive device is hopping on one leg with a walker. She baby sits young 
grandchildren and needs this prosthetic foot. The Plan denied your request. The Plan says the request for an 
initial prosthesis with K3 foot does not meet Medicare criteria as 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 pre-approve a prosthetic leg with an advanced foot 
feature. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support the enrollee is a K3 
ambulator given her history of significant medical comorbidities and documentation of deconditioning. The 
8/3/22 document notes the enrollee has diabetes, arthritis, tenuous skin condition, PAD, peripheral neuropathy, 
cognitive impairment, back pain that has gotten worse since amputation with weakened core muscles, joint 
impairment due to weakness and deconditioning, vision impairment, trauma conditions with nerve damage and 
loss of protective sensation, and hip joint compromise from weakness and deconditioning. These findings are 
not consistent with a need for an advanced foot. 
 
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 prosthetic leg with an advanced foot feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature (L5981, 
L5986).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to regain her independence and 
needs the physical therapy provided in inpatient rehab. The Plan denied your request. The Plan says the request 
is not medically necessary, the services the enrollee needs can be provided safely 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. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 16, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 the lab services provided on August 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation hours per month. 
 
You asked the Plan to pre-approve additional transportation hours per month. You say that the services are 
necessary. The Plan denied your request. The Plan says assistance beyond the 8 allowable hours per month is 
not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 8 hours of care team assistance per month.  
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage. Therefore, we decided that the Plan does not 
have to pre-approve additional transportation hours per month.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization of the knee (CPT code(s): 
37243 X 4, 75710 X 4 and 75716 X 4). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are limited large-scale, long-term references showing the safety and efficacy of the 
requested procedure in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
genicular artery embolization of the knee, in this case, 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular artery embolization of the knee (CPT code(s): 37243 X 4, 75710 X 4 and 75716 
X 4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic testing must be billed with 
the DEX-Z code. 
 We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
DEX-Z code. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
February 11, 2022.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is weight-bearing 
as tolerated. There is no evidence-based support for an IRF admission for hip fracture rehabilitation. The enrollee does not require intensive rehabilitation services and has very limited capacity to participate in 
intensive therapy. He does not require frequent physiatry oversight. He is on stable medications for his 
Parkinson's. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from  
April 24, 2022, to April 26, 2022. 
 
You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says continuation of SNF care 
does not meet the Medicare 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee 
had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy (PT) and 
occupational therapy (OT). The enrollee was at a standby assist to independent level with functional mobility 
including gait to 150 feet. The enrollee required varying assist with activities of daily living. There are no 
identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee 
does not require skilled nursing or therapy services on a daily basis. As a practical matter, this 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 pay for SNF care provided from April 24, 2022, to April 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop 
recorder is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested implantable loop recorder. 
 
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 an implantable loop recorder. Our 
reviewer says that the enrollee does not meet criteria for the requested implantable loop recorder. Our physician 
reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an implantable loop recorder. In summary, there is insufficient 
documentation to support the medical necessity for insertion of an implantable loop recorder in this enrollees 
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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on April 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code is not supported. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care rendered on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436 and 84479 billed for date of service 
July 27, 2021. 
 You asked the Plan to pay for procedure codes 84436 and 84479. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says the payment for codes 84436 and 84479 is 
bundled into the payment for code 84439. 
 
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 codes 
84436 and 84479 are both column II codes to column I code 84439 with modifier indicators of 0. The column 
II codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 84436 and 84479 billed for date 
of service July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service November 
11, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99053 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99053 billed for date of service November 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the enrollee has osteoarthritis in their left hip and 
bilateral knee. You say that the requested drug is covered for treatment of pain in osteoarthritis of the knee in 
patients who failed to respond to conservative non-pharmacologic therapy and analgesics. The Plan denied 
your request. The Plan says the requested drug is not covered for joints other than the knees. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation of joints other than the 
knees are considered not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Orthovisc (J7324).