Persius/hicric huggingface dataset:
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 you are appealing the denial of admission with 
supporting medical records. The Plan denied your request. The Plan says based on Medicare guidelines the 
inpatient rehabilitation facility 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for weakness and falls. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. While the medical records support 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 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

  
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is necessary to 
sustain a safe and sustainable discharge. The Plan denied your request. The Plan says an LTACH admission is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's rehabilitation was unsuccessful, and 
can no longer walk since no ambulatory ability, and can no longer transfer, toilet, or shower. The Plan denied 
your request. The Plan says the record shows that the enrollee does not meet Medicare guidelines for services 
in a skilled nursing facility. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is not shown to be acutely below baseline, or to be able to participate in 
skilled therapy. The enrollee does not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our 
reviewer also found that the enrollee does not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) 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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to the LTACH would be 
medically beneficial to the enrollee. The Plan denied your request. The Plan says that the admission to a 
LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 provided on April 5, 2022. 
 
You asked the Plan to pay for procedure code 85060. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for procedure code 85060 provided on April 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from more therapy for 
stroke recovery and wound care for ulcers, and has methicillin-resistant staphylococcus aureus 
(MRSA).  The Plan denied your request. The Plan says admission is not reasonable or necessary and does not 
meet Medicare criteria for SNF coverage. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the nature and frequency of the enrollee's wound care is unclear. The enrollee does 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our reviewer also found that the enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested facet joint injections. 
 
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 facet joint injections. Our reviewer 
says that the enrollee does not meet criteria for the requested facet joint injections. Our physician reviewer 
found the LCD requires that the degree and duration of pain relief be documented after a block and that if 
another is to be conducted, it has to be documented as 80% improvement. Therefore, at this time, the request is 
deemed not medically reasonable and 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Partially Favorable

 
You asked the Plan to pre-approve a ganglion impar block and insertion of a dorsal root ganglion (DRG) 
stimulator.. You say that these services are medically necessary. The Plan says that this request is considered 
experimental/investigational. 
 
We decided that the Plan has to pre-approve ganglion impar 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 ganglion impar block. Our reviewer 
says that the requested ganglion impar block is medically reasonable and necessary. Our physician reviewer 
found ganglion impar block is the standard of care for the treatment of coccydynia.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ganglion impar block and DRG stimulation have been met. Therefore, we 
decided that the Plan has to pre-approve ganglion impar block.  
 
We also decided that the Plan does not have to pre-approve DRG stimulation. 
 
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 DRG stimulation. Our reviewer says 
that the requested DRG stimulation is noy medically reasonable and necessary. Our physician reviewer found 
DRG and spinal cord stimulation would be experimental/investigational for this diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DRG stimulation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve DRG stimulation. 
 
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: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Hyaluronan or derivative (J7318). 
 
You asked the Plan to pre-approve Hyaluronan or derivative. The Plan denied your request. The Plan says that 
Hyaluronan injections are not medically necessary given your current conditions. 
 
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. The Plan did not provide a copy of the applicable 2023 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial in 
this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial in this case. Therefore, we decided that the Plan has to 
pre-approve Hyaluronan or derivative (J7318).  
 
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 therapeutic facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested injections are not medically 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request should have been for diagnostic medial branch blocks, and not therapeutic injections. The enrollee has not yet had diagnostic medial branch blocks. 
 
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 therapeutic facet joint injections (64493, 64494).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you had 4 falls in the last month resulting in two 
concussions. You also say that you have problems with mobility and walking and require more assistance. The 
Plan denied your request. The Plan says admission is not reasonable or necessary and you do 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 pre-approve 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 you are ambulating household distances. You do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. Your care needs, custodial and intermittent, can, as a 
practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 19, 2022 to 
March 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 19, 2022 to 
March 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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 lab services provided on December 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear myocardial perfusion imaging study (78452). 
 
You asked the Plan to pre-approve a nuclear myocardial perfusion imaging study. You say that you would like 
the enrollee to be approved for a cardiac stress test. The Plan denied your request. The Plan says the requested 
nuclear myocardial perfusion imaging study is denied based on lack of medical necessity per Medicare 
guidance. 
 
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the 
presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or 
abnormalities on cardiac testing will be considered screening and denied as not covered by Medicare. 
 
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 nuclear myocardial perfusion imaging 
study. Our physician reviewer found the enrollee has no chest pain or dyspnea. There is no documentation that 
the electrocardiogram shows an uninterpretable pattern. Our reviewer found there is no evidence provided that 
would support the need for radionuclide stress testing at this time. Our physician reviewer also found that there 
is insufficient documentation to support the medical necessity for the requested cardiac stress testing 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 a nuclear myocardial perfusion imaging study have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a nuclear myocardial perfusion imaging study (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of a modality to 1 or more areas; infrared (CPT 
code 97026) and application of a modality to 1 or more areas; hot or cold packs (97010) provided from 
December 2, 2021, through December 10, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Furthermore, for code 97026, acupuncturists are not able to be 
reimbursed by Medicare. Acupuncturists are included in the list of individuals that are not eligible to enrollee 
in Medicare. Therefore, we decided that the Plan does not have to pay for application of a modality to 1 or 
more areas; infrared (CPT code 97026) and application of a modality to 1 or more areas; hot or cold packs 
(97010) provided from December 2, 2021, through December 10, 2021.