Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found Medicare criteria requires 50% pain relief which has lasted 3 months. The request is too early 
to meet Medicare criteria in this case as the most recent injection was less than 3 months ago. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
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 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary at this time as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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 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 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 enrollee is currently undergoing treatment at an IRF for a chronic sacral wound 
and debilitation. The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires the 
services provided at a LTACH. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental for back pain. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an 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 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 medically stable 
and does not need physical medicine and rehabilitation (PM&R) physician's close supervision 3 times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or documented. At the current functional level, the enrollee does 
not require 3 hours a day five days a week of IRF therapies with interdisciplinary management. The enrollee 
needs continued physical therapy (PT), speech therapy (ST), and occupational therapy (OT) at home. The lack 
of complexity of the enrollee's medical condition and lack of nursing needs do not support an acute hospital 
inpatient rehabilitation admission with an interdisciplinary approach to rehabilitation care. Documentation does 
not support the medical necessity for admission to 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: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of a new patient (99204) provided on December 2, 2021. 
 
You asked the Plan to pay for the office or other outpatient visit for the evaluation and management of a new 
patient. You say that you would like this claim reprocessed and approved for payment. The Plan denied your 
request. The Plan says the claim has not been billed as required by Medicare coding regulations. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation indicates 
that a previous evaluation and management code was billed by the same provider on October 29, 2021. 
Therefore, the claim on December 2 was incorrectly billed with a CPT code indicating the professional services 
were provided to a new patient. Based on this information, we decided that Medicare rules for coverage of the 
office or other outpatient visit for the evaluation and management of a new patient have not been met. 
Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the 
evaluation and management of a new patient (99204) provided on December 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you have driven yourself to some of your 
appointments, however, you need a new car or replacement of your engine. You are requesting additional 
transportation for extra miles so you can continue your treatments with your specialist. The Plan denied your 
request. The Plan says you are requesting an additional 12 miles for a total of 62 miles and your benefit only 
allows 50 miles. The Plan also says you have exceeded your benefit limit. 
 
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 up to 72 one-way trips and each trip must not exceed 50 miles of driving distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthesis socket (L5999). 
 
You asked the Plan to pre-approve the prosthesis socket. You say that this socket is medically necessary. The 
Plan denied your request. The Plan says the requested code is not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that code L5999 must not be used to bill for any 
features or functions included in the socket or addition codes. Use of L5999 is incorrect coding. 
 
We looked at the file and Medicare rules. The requested prosthesis socket is not separately payable using code 
L5999. Based on this information, we decided that Medicare rules for coverage of the prosthesis socket have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthesis socket (L5999).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block. 
 
You asked the Plan to pre-approve a lumbar/sacral facet joint block. You say that the requested lumbar/sacral 
facet joint block is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested lumbar/sacral facet joint block. 
 
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 lumbar/sacral facet joint block. Our reviewer says that the enrollee does not meet criteria for the requested lumbar/sacral facet joint block. Our 
physician reviewer found there is presence of ongoing radicular pain and a documented herniated disc.  This 
does not meet Medicare criteria which requires that there not be another probable pain generator. 
 
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 lumbar/sacral facet joint block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lumbar/sacral facet joint block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hot tub. 
 
You asked the Plan to pre-approve the hot tub. You say that the hot tub is medically necessary. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a hot tub.
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 enrollee does not meet criteria for SNF 
admission. 
 
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 rules also 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 
enrollee meets criteria for SNF admission. Our physician reviewer found based on the limited documentation 
provided, the health plans denial should be overturned.  Per the health plan, the enrollee was admitted to an 
acute care hospital on July 15, 2022, with a small subarachnoid hemorrhage following a fall. The health plan 
argues that the enrollee is not in need of SNF services citing therapy records from July 20, 2022, July 25, 2022, 
and August 3, 2022. These records have not been provided to the IRE for review.  As such, the health plan has 
failed to support its denial. 
 
We looked at this physician's review, the file, and Medicare rules. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcutaneous Electrical Nerve Stimulator (TENS) 
therapy. 
 
You asked the Plan to pre-approve TENS therapy. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says TENS therapy is not covered for chronic lower back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS machines are only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a TENS machine have not been met. The documentation does not support that you have acute post 
operative pain or chronic pain other than low back pain. Therefore, we decided that the Plan does not have to 
pre-approve Transcutaneous Electrical Nerve Stimulator (TENS) therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite blood glucose test strips, a non-preferred 
brand product. 
 
You asked the Plan to pre-approve Freestyle Lite blood glucose test strips. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says there is no medical reason the 
enrollee cannot use a preferred brand blood glucose test strip. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file, the Plan's contract, and Medicare rules. The services at issue are diabetic testing strips 
from a non-preferred brand. The services are available from the Plan's preferred brand. Therefore, we decided 
that the Plan does not have to pre-approve Freestyle Lite blood glucose test strips, a non-preferred brand 
product.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the powered pressure reducing mattress overlay/pad (E0181) 
provided on July 20, 2021. 
 
You asked the Plan to pay for the powered pressure reducing mattress overlay/pad. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim for 
durable medical equipment has not been billed as required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must specify whether equipment is rented 
or purchased. 
 
We looked at the file and Medicare rules. In this case, the claim does not indicate that an appropriate HCPCS 
modifier was billed with the ordered equipment to indicate whether it was purchased or rented. Based on this 
information, we decided that Medicare rules for coverage of the powered pressure reducing mattress 
overlay/pad have not been met. Therefore, we decided that the Plan does not have to pay for the powered 
pressure reducing mattress overlay/pad (E0181) provided on July 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional PT visits. 
 
You asked the Plan to pre-approve eight additional PT visits. You say that to end therapy at this time will only 
lead to further loss of mobility and eventual deterioration that could require surgery or confinement to a 
wheelchair. The Plan denied your request. The Plan says PT is not medically necessary and based on clinical 
notes, your mobility and motion have not significantly changed. 
 
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 pre-approve eight additional PT 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 that the requested services are not part of a maintenance 
program, and  the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eight additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eight additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from August 23, 2021, through 
August 24, 2021, at DRG 291. 
 
You asked the Plan to pay for inpatient services at DRG 291. You say that you disagree with the DRG 
downgrade. The Plan denied your request. The Plan says secondary diagnosis code J96.21 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code J96.21, defined as acute and 
chronic respiratory failure with hypoxia. 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 
inpatient services at DRG 291. Our reviewer says that the documentation does not support secondary diagnosis 
code J96.21. Our physician reviewer found the emergency department provider indicated there was no 
diagnosis of asthma or chronic obstructive pulmonary disease previously, but that the presentation was 
consistent with an exacerbation of reactive airway disease and heart failure. The discharge summary noted that 
dyspnea had improved with diuresis as well as chronic obstructive pulmonary disease exacerbation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from August 23, 2021, through August 24, 2021, at DRG 291.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on December 8, 2021, by an OON 
provider. 
 
You asked the Plan to pay for anesthesia. You say that are requesting a reconsideration to review the medical 
records to the services provided to the enrollee. This information details the enrollee's history and symptoms 
that led to the physician requesting these services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for anesthesia provided on December 8, 2021, by an 
OON provider.