Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits in your home. 
 
You asked the Plan to pre-approve the home health services. You say that you need these services. You say that 
you do not have anyone to help you. You say that you were seeing some progress with physical therapy, but 
you need more for you to improve. The Plan denied your request. The Plan says the requested home health 
services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found 
appears to have improved with therapy to the point of being able to manage her mobility for household 
distances, transfers and activities of daily living independently or with supervision. The reviewer found that the 
therapy notes indicate your goals have been met. After twelve physical therapy treatments, records do not 
support that the complexity of your conditions are such that the skills of a professional therapist are required to 
achieve further improvement in your symptoms or functional status. Therefore, the reviewer found that the 
requested home health services 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 the home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy (PT) visits in your home.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 16, 2021 billed with 
codes 81479, 81240, 81241, 81291, 81328, 81355, 81401, 81225, 81226, 81227, 81230, 81231, 0031U and 
0078U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are an independent diagnostic 
laboratory that tests Pathology, Medication management and toxicology samples sent from clinics and 
providers for patients they have determined require such testing. The Plan denied your request. The Plan says 
the service does not meet the LCD/NCD coverage requirements. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 16, 2021 billed with codes 81479, 81240, 81241, 81291, 81328, 81355, 81401, 81225, 81226, 81227, 
81230, 81231, 0031U and 0078U.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept back procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept back procedure. You say that the provider would like to 
perform the procedure at L3 and L4 vertebral bodies on the enrollee. The Plan denied your request. The Plan 
says the enrollee's request is not medically necessary because there is little evidence in the medical literature to 
suggest that this is an appropriate procedure for the enrollee's back pain. The Plan states it is not an accepted 
standard of medical practice for the diagnosis or treatment of back pain and it is considered experimental and 
investigational. 
 
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 back procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found 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 L3 and L4, 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 back procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the intracept back procedure (CPT code 64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 8 and 20, and pontic 
(D6245) for tooth # 19. 
 
You asked the Plan to pre-approve the fixed bridge. You say that you have 3 teeth that need a crown. You say 
the bridge is not covered. You also say that that the bridge is needed because it connects the teeth so you can 
chew properly. The Plan denied your request. The Plan says the fixed bridge is not listed as a covered dental 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested fixed bridge is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns (D6740) for teeth # 8 and 20, and pontic (D6245) for tooth # 19.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is not enough evidence that this type of radiation therapy guidance is needed or 
effective for the enrollee's skin cancer. 
 
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 IMRT would not be furnished in accordance with accepted standards or practice. 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 intensity modulated radiation therapy (IMRT).
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 you need these services. The Plan denied 
your request. The Plan says the admission and care are 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 provided records do not indicate you require services at the LTACH that are not 
available at the acute care hospital where you are currently receiving care. There are no services available at the 
LTACH that you require that are not available at the health care setting being offered by the health plan. 
Therefore, the reviewer found the requested LTACH services are not medically reasonable or necessary in this 
case. 
 
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 0239U billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code 0239U. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 0239U is bundled into payment for code 0337U. 
 
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 0239U 
is a column II code to column I code 0337U. 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 0239U billed for date of service April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
additional routine transportation trips. The Plan denied your request. The Plan says this request is not covered 
by your Health Plan. 
 
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.  
 
 We looked at your request, the records in the case file, and the rules. The 37th trip and beyond is not a covered 
benefit. The Plan contract says up to 36 one-way trips, combined in and out-of-network, are covered each year 
(limited to ground transportation only). Therefore, your request exceeds your benefit. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergent ambulance services. 
 
You asked the Plan to pre-approve the non-emergent ambulance services. You say that the enrollee has not 
received enough physical therapy to be discharged on their own. The Plan denied your request. The Plan says 
the Medicare rules have not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance services. 
Our physician reviewer found the review has determined that the documentation did not support that other 
means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this enrollee. The documentation did not support that the enrollee needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport. The documentation did not support that the ambulance transport was medically reasonable and 
necessary for the enrollee. 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 non-emergent ambulance services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the non-emergent ambulance 
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 you have difficulty doing daily activities due to the 
lack of strength and oxygen. You say that rehabilitation will allow you to get stronger to be able to live 
independently. The Plan denied your request. The Plan says the record shows that you do not meet the 
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 you are ambulating more than 100 feet. Daily skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of your condition. 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.  
 
 
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 an inpatient admission. 
 
You asked the Plan to pre-approve an inpatient admission. You say that you recommend an inpatient admission 
to the multidisciplinary program for treatment of migraine headaches. The Plan denied your request. The Plan 
says the clinical documentation does not show that the enrollee has a significant neurologic impairment or 
conditions, and that the enrollee requires neurologic assessment at least 3 times per 24 hours. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 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 inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for an inpatient admission are met in this case. 
Our physician reviewer found the record does not show that the admitting physician reasonably expects that the 
enrollee's necessary hospital care will span two midnights. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the medical records submitted, admission to an inpatient rehabilitation facility 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 the enrollee has Parkinson's disease, a wound on his leg and is living at home with 
increased gait problems and frequent falls. Medical problems are stable.  
 There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to continue your care at 
the requested LTACH. The Plan denied your request. The Plan says admission to the requested 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 provided documentation does not indicate the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. Therefore, the reviewer found that the requested LTACH services are 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 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 arthrodesis, posterior or posterolateral technique, single 
level; lumbar (CPT code 22612). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee's records do not show that they have a spinal fracture or deformity that 
would require single level fusion without decompression. The Plan states spinal fusion without decompression 
is not reasonable and necessary treatment for spinal stenosis. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested arthrodesis, posterior 
or posterolateral technique, single level, lumbar (CPT 22612) at L4-5 using the MinuteMan G3-R MIS fusion 
plate, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (CPT code 22612).
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. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for continued skilled nursing facility services. 
 
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 ambulating one hundred feet and tending to activities of daily living 
skills with minimal supervision. 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 skilled nursing facility (SNF) care.