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 admission to IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. Other alternate settings could be reviewed if requested such as skilled nursing facility, 
outpatient setting or home health 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 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology procedures of the lower extremities 
(code 73560) provided on July 11, 2022. 
 
You asked the Plan to pay for the diagnostic radiology procedures of the lower extremities. The Plan denied 
your request. The Plan says the member was in hospice on this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for diagnostic radiology procedures of the lower extremities 
(code 73560) provided on July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 billed for date of service September 
16, 2022. 
 You asked the Plan to pay for procedure code(s) 88360. You say that this service was coded correctly. The Plan 
denied your request. The Plan says this code is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88360. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88360 billed for date of service September 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99220) provided on August 18, 2022. 
 
You asked the Plan to pay for the observation care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed service. 
 
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 99220 is Initial observation care, requiring 
comprehensive history, a comprehensive examination and medical decision of high complexity. 
 
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 observation care. Our reviewer says that the code billed is 
not supported. Our reviewer found the records do not show medical decision making of high complexity. 
 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 observation care have not been met. Therefore, we decided that the Plan 
does not have to pay for observation care (99220) provided on August 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on July 11, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that this provider type is not eligible in the Medicare program. 
 
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. Specifically, the Plan has not provided a Medicare rule to substantiate that a 
licensed clinical social worker is not eligible to enroll in Medicare. Therefore, we decided that the Plan has to 
pay for psychotherapy provided on July 11, 2022.  
 
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 the destruction by neurolytic agent, paravertebral facet 
joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and each 
additional facet joint (64636 x 2). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because your records show you do 
not have the absence of untreated radiculopathy. 
 
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 physician reviewer 
found the enrollee has multi-level disc protrusions with foraminal stenosis. The enrollee has radicular 
symptoms. The enrollee has other pain generators that have not been addressed. The criteria of the LCD are not 
met, and the request is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and each additional facet joint 
(64636 x 2).
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. The Plan denied your request. The Plan says the enrollee's records 
do not show that you need an intensive team for your care, services needed can be provided safely in other 
settings, skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close acute 
monitoring and care for another 4 to 6 weeks. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee's needs can be met in another setting. 
 
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 is improving but still requires acute care services before 
transitioning to a lower level of care. The medical records do not indicate that the enrollee requires services that 
she is not currently receiving but that would be available at the LTACH 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic brachytherapy (77280, 0394T, 77290). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are insufficient long-term efficacy and safety data to support the 
routine use of electronic surface brachytherapy. The Plan states the enrollee's records do not show that the 
enrollee has undergone clinical staging, consideration for resection of the remaining lesion, or consideration for 
alternate treatment options. 
 
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 there are insufficient long-term efficacy and safety data to support the routine use of electronic surface brachytherapy. Further, the enrollee's records do not show that the enrollee has undergone clinical 
staging, consideration for resection of the remaining lesion, or consideration an alternate treatment option. 
 
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 the electronic brachytherapy (77280, 0394T, 77290).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc intradiscal therapy. 
 
You asked the Plan to pre-approve the requested VIA Disc intradiscal therapy. You say that this should be 
allowed as it would be beneficial for the enrollee. The Plan denied your request. The Plan says this treatment 
remains experimental at this time. 
 
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 VIA Disc intradiscal 
therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the VIA disc procedure is experimental. More research is needed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested VIA Disc intradiscal therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve VIA Disc intradiscal therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 3 Sensor. 
 
You asked the Plan to pre-approve FreeStyle Libre 3 Sensor. You say that you need the requested sensor. The 
Plan denied your request. The Plan says the sensor does not meet Medicares definition of durable medical 
equipment (DME) and, therefore, is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve FreeStyle Libre 3 Sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the minuteman G3R interspinous device 
to L3-L5 (22612, 22840, and 20930). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Minuteman interspinous device in 
the setting of lumbar spinal stenosis 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the minuteman device is experimental. More reserarch is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of the minuteman G3R interspinous device to L3-L5 (22612, 22840, and 
20930).
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 enrollee needs to continue aggressive physical 
and occupational therapy and is willing and able to participate in daily therapy services. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in an inpatient rehabilitation 
facility. 
 
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 does not require treatment by multiple therapies. 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary to regain your highest 
functional level of independence to return home safely. The Plan denied your request. The Plan says your needs 
can safely be met in the hospital setting. 
 
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 you do not require treatment by multiple therapies. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0245U) provided on September 29, 2022. 
 
You asked the Plan to pay for lab services. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (0245U) provided on 
September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you determined that in 
addition to the normal postoperative regime of physician therapy, a continuous motion device at home and 
baby aspirin for 90 days, that the enrollee would benefit from the use of a pneumatic compression device. The 
Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0675).
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 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 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.