Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has 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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 an Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar-sacral orthosis (L0637) to be provided by an 
out-of-network DME provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there is an in-network DME provider that can perform the service 
the enrollee needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the lumbar-sacral orthosis (L0637) to be provided by an out-of-network DME provider.
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 medically 
necessary. The Plan denied your request. The Plan says you do not meet all the requirements for an LTACH 
admission. 
 
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 you appear to have been improving, but it is not clear whether you are 
appropriate for transfer as no recent notes were provided for review. Additional acute care services can safely 
be administered at the current facility until more appropriate for a lower level of care. Our reviewer found that 
you do 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator and supplies. 
 
You asked the Plan to pre-approve the stimulator and supplies. The Plan denied your request. The Plan says 
this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Per NCD 160.2, the requested stimulator and supplies are covered. 
Based on this information, we decided that Medicare rules for coverage of the stimulator and supplies have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an external upper limb tremor 
stimulator and supplies.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT), of the thorax, diagnostic; without 
contrast material (71250). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that the requested service is not medically necessary. 
 
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 this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that you are currently a daily smoker of 
5 cigarettes per day but have smoked 4 packs per day for 20 years in the past. You reported seasonal allergy-
related congestion and the pulmonary exam showed a pulse oximetry of 91%, decreased breath sounds, and 
rhonchi. Based on the provided documentation, the request for a CT scan of the thorax is reasonable and 
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 this service have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT), of the thorax, diagnostic; without contrast material (71250).  
 
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: 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 are appealing the denial. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. Records support that services in the home 
with home health care or in a long-term care facility on a part time basis are appropriate 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 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an interdisciplinary team 
approach to reach their goal of being independent. You say that the enrollee can participate in therapy 3 hours a 
day and 5 days a week to focus on improving their functional mobility, and proper use of an assistive device to 
prevent falling. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
the enrollee's needs can be met at a lower level of care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital stay with an interdisciplinary approach to rehabilitation care. The enrollees medical 
conditions are stable on outpatient medications with no issues that require a physicians evaluation three or 
more times per week in a hospital setting. Treatment such as outpatient therapy, home health therapy or a 
skilled nursing facility are more appropriate. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure improves quality of life. 
The Plan denied your request. The Plan says the enrollee has not failed conservative management. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental for back pain. More research is needed to show its 
efficacy. Therefore, the requested service 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show its safety and 
efficacy. Therefore, the request is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (84165) provided on August 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this service was medically necessary and was a 
covered benefit. The Plan denied your request. The Plan says this claim was billed with an incorrect place of 
service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services with the correct 
place of service (POS) code. The rules say that for services rendered to a patient who is a registered inpatient or 
an outpatient of a hospital, the correct POS code is that of the appropriate inpatient or outpatient hospital POS 
code, regardless of where the face-to-face service occurs. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, this claim was billed with POS code 22 (on 
campus  outpatient hospital); however, the record shows that the enrollee was registered inpatient status from 
August 21, 2022, to September 6, 2022. This means that this claim must be submitted with an appropriate 
inpatient hospital POS code. Therefore, we decided that the Plan does not have to pay for laboratory services 
(84165) provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular radiofrequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve RFA. You say that you need this service. The Plan denied your request. The 
Plan says the requested service is 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 RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested service is considered experimental and investigational. Therefore, the reviewer found that 
the requested RFA 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a genicular radiofrequency ablation (RFA) (64624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romiplostim injection (Nplate) (J2796). 
 
You asked the Plan to pre-approve Nplate. The Plan denied your request. The Plan says that Romiplostim 
injection (Nplate) is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Nplate. Our reviewer says that Nplate is 
not reasonable or necessary for the enrollee. Our physician reviewer found the requested use of Romiplostim 
injection (Nplate) is not Food and Drug Administration-approved for the enrollee's diagnosis of drug 
(Methotrexate and Humira) induced thrombocytopenia. Our reviewer found that the requested use of 
Romiplostim injection (Nplate) to treat drug (Methotrexate and Humira) induced thrombocytopenia is not 
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare 
and Medicaid Services (CMS)-approved medical journal. Our physician reviewer also found that the requested 
use of Romiplostim injection (Nplate) to treat drug (Methotrexate and Humira) induced thrombocytopenia is 
not indicated, supported or recommended in any of the compendia. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nplate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Romiplostim injection (Nplate) (J2796).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that without IRF services the enrollee will not get their 
independence back. The Plan denied your request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479) provided on August 3, 2022. 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial and are requesting 
reconsideration for payment on this claim. The Plan denied your request. The Plan says the enrollee's coverage 
required pre-certification for the reported service. The pre-certification requirements were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that PGx testing is considered reasonable and 
necessary in limited circumstances. Only approved tests will be reimbursed consistent with the effective date of 
the coverage determination. 
 
We looked at the file and Medicare rules. The records show that a pre-certification was required for the 
requested testing. The records show that although medications were being considered for augmentation or 
starting/switching to, there is no documentation of such provided in the medical records sent for review. 
Medicare rules confirm that PGx testing is not considered reasonable and necessary merely on the basis of a 
patient having a particular diagnosis. Based on this information, we decided that Medicare rules for coverage of 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic 
testing (81479) provided on August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (31225) provided on August 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 31225 is "Maxillectomy; without orbital exenteration". 
 
We asked our coder 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 services. Our reviewer says that the use of code 31225 is 
not supported by the records provided. Our reviewer found that the operative report does not include 
documentation to support maxillectomy was performed. The operative report documents Modified medial 
maxillectomy, right. Using needle tip Bovie cautery, incision was made along the mucocutaneous junction, 
brought anterior to the maxillary wall and the inferior and posterior vertical osteotomies were performed. 
Medial maxillary wall was removed, inferior maxillary ridge drilled down with a 15-degree diamond bar.  In 
this case, procedure code 31225 cannot be verified.  
We looked at this coder'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 pay for the services (31225) provided on August 3, 2022.
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 enrollee requires an extended 
hospital level of care which would be best served by transitioning the enrollee to the LTACH. The Plan denied 
your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require 
transfer to an LTACH. 
 
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 should only require short-term additional acute care services that can 
safely be administered at the current facility. Transfer to the LTACH would not be clinically advantageous and 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until November 9, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on September 2, 2021.