Persius/hicric huggingface dataset:
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 requested admission to an IRF is not medically 
necessary. 
 
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 documentation shows that you have functional impairments however, there are no 
complex functional deficits, active medical issues, or specific etiology to functional impairments specified 
thus the complexity of your documented nursing, medical and rehabilitation needs would not be expected to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 that the enrollee was admitted with altered mental status in the setting of sepsis from 
viral pneumonia and chronic obstructive pulmonary disease exacerbation.  The record indicates that the 
enrollee is improving but still requires acute care services before transitioning to a lower level of care. The 
enrollee continues to receive acute care services, and these have not been denied. The medical record does not 
indicate that the enrollee requires services that she is not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says you do not meet the diagnostic criteria of both Alzheimer's disease 
and frontotemporal dementia. 
 
The Plan follows Medicare rules. Medicare rules say that FDG Positron Emission Tomography (PET) scans are 
covered for either the differential diagnosis of frontotemporal dementia (FTD) and Alzheimers disease (AD) 
under specific requirements 
 
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 PET scan of the brain. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found documentation does not support 
that you meet diagnostic criteria for either frontotemporal dementia (FTD) or Alzheimers disease (AD). In 
such a setting/context, the request would not meet the basic requirement for coverage. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from April 15, 2021, to 
April 29, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says there was no clinical evidence to validate the billed code. 
 
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 provided with diagnosis code J15.6, defined as pneumonia, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our physician reviewer found that the enrollee presented to the 
emergency room with shortness of breath. The exam showed a left lower lung infiltrate and hyponatremia. The 
enrollee had no evidence of positive sputum or a blood culture of a gram-negative organism. The review has 
determined that the documentation did not support the billed diagnosis, J15.6.  
 
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 hospital services provided from April 15, 2021, to April 29, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81514, 87500, 87506 and 
87653 provided November 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the provider has not submitted 
progress notes that are needed in order to determine the clinical utility of the testing. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether CPT codes 81514, 87500, 87506 and 87653 for the enrollee is a 
covered. In this case the record indicates that the enrollee underwent the above tests.  The record provided is 
insufficient to establish the medical necessity of the requested services.  The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are not satisfied.  The requested service is not 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 81514, 87500, 87506 and 87653 provided November 
3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the facet joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the facet joint. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation will be covered after the 
patient has had at least two (2) medically reasonable and necessary diagnostic medial branch blocks, with each 
one providing a consistent minimum of 80% sustained relief of primary (index) pain. 
 
We looked at the file and Medicare rules. In this case, the evidence supports that the first medial branch block 
only resulted in 30% sustained pain relief. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation of the facet joint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the facet joint.
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 this is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for surgical management of bowel obstruction and hernia. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. In this case, the enrollee does 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. In conclusion, there is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve invasive vascular procedures. 
 
You asked the Plan to pre-approve invasive vascular procedures. You say that the records provided support the 
need for the requested services. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary because there is no documentation of the enrollee having a history of blood clots in either 
leg. The Plan says that the request does not describe problems with varicose veins of the vaginal/vulvar area or 
any other documentation explaining the need for the requested services. 
 
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 invasive vascular procedures. Our 
reviewer says that invasive vascular procedures are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has documentation of diabetes, peripheral artery disease and 
diminished pedal pulses bilaterally with coldness to the lower extremities bilaterally.  Despite this, she is status 
post bilateral greater saphenous and small saphenous vein ablations.  It is not possible to attribute the enrollees 
symptoms to her veins without documentation of satisfactory perfusion to the lower extremities bilaterally. 
Additionally, there is no evidence of whole leg edema and no evidence of proximal venous obstruction on the most recent venous studies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of invasive vascular procedures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve invasive vascular procedures.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an 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 the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility until more appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that the documentation supports medical 
necessity. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for 
code 0089U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 81345 is a column II code to column I code 0089U. This claim has 
not been billed with an appropriate modifier to bypass the edit. 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 code 81345 
billed for date of service May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support that the 
requested procedure is medically necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the Intracept procedure in the setting of vertebrogenic low back pain have not been 
demonstrated in the peer-reviewed literature. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L4, L5, and S1 levels, 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you need more therapy and cannot do it 
alone due to having dementia and not being able to remember. The Plan denied your request.  The Plan says based on Medicare guidelines the skilled nursing facility care you are requesting do not meet the 
requirements for approval. 
 
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 continued 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 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 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 can, as a practical manner, 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the procedure was rendered in the appropriate 
place of service. The Plan denied your request. The Plan says the code is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. We find that code 85060 was billed with an outpatient hospital place of service 
code. No payment is recognized for code 85060 furnished to hospital outpatients. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 85060 billed for date of service July 25, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the leg. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has had surgery and is complaining 
of increasing pain. The Plan denied your request. The Plan says that there should be a reason why a different 
test cannot be done. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 medically reasonable and necessary. Our physician reviewer found that the record 
indicates osteoarthritis of the hip. The record indicates that the enrollee has had recent arthroplasty and is 
having increased pain. Plain films are concerning for periprosthetic fracture. The elements of the coverage 
criteria are satisfied. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) scan of the leg.  
 
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.