Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the periodic comprehensive preventive medicine 
reevaluation and management of an individual (99397) provided on November 21, 2022. 
 
You asked the Plan to reimburse you for the physical exam. You say that this should be covered. The Plan 
denied your request. The Plan says the annual physical exam benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that routine physical checkups are not covered when 
performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical exam have not been met. The record indicates that one physical exam is covered per 
calendar year. The record also indicates that the Plan paid for this service within the 2022 calendar year. 
Therefore, we decided that the Plan does not have to reimburse you for the periodic comprehensive preventive 
medicine reevaluation and management of an individual (99397) provided on November 21, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care from March 
23, 2023, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you qualify for ongoing SNF coverage. You do not have documented skilled nursing 
needs. You do have documented skilled therapy needs. As such, additional therapy to provide teaching, 
monitoring and exercises corresponding to this change is medically necessary and reasonable. Daily skilled 
services are required to establish a maintenance program or to prevent deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve the continuation 
of skilled nursing facility (SNF) care from March 23, 2023, forward.  
 
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: 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 services are necessary for the 
enrollee to receive the care needed and return to prior level of living independent. The Plan denied your 
request. The Plan says the enrollee can receive the care needed in the hospital. 
 
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 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 they 
are 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography 
(Virtual Colonoscopy). 
 
You asked the Plan to pre-approve a computed tomographic (CT) colonography (Virtual Colonoscopy). You 
say that a computed tomographic (CT) colonography (Virtual Colonoscopy) is medically necessary. The Plan 
denied your request. The Plan says the requested computed tomographic (CT) colonography 
(Virtual Colonoscopy) does not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that Screening computed tomographic colonography 
(CTC), effective May 12, 2009, is non-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 a computed tomographic (CT) 
colonography (Virtual Colonoscopy). Our reviewer says that the requested computed tomographic (CT) 
colonography (Virtual Colonoscopy) is not medically necessary in this case. Our physician reviewer found that 
the available records do not support that you are contraindicated to a colonoscopy nor to procedural sedation. 
There is no high-risk family history nor reports of prior incomplete nor technically limited colonoscopies that 
were provided.  
 
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 computed tomographic (CT) colonography (Virtual Colonoscopy) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic (CT) 
colonography (Virtual Colonoscopy).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support necessity for admission to an IRF and the 
complexity of the enrollee's nursing, rehabilitation, and medical needs (no complexity) does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the 
enrollee may benefit from physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation 
needs can be provided in a lower intensity and alternate setting such as in a skilled nursing facility (SNF). 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services rather than a 
skilled nursing facility. 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: 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 requesting reconsideration for the denial of 
a continued SNF stay. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a 
continued stay in the SNF. 
 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 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. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee's function was at or near their new baseline level of function and they could 
be discharged to a lower level of care for further services. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
August 20, 2021. 
 
You asked the Plan to pay for the PCR panel. The Plan denied your request. The Plan says this 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 pay for the PCR panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that urine PCR amplification techniques raise considerable concerns regarding contamination from one 
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results 
may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of 
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
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 PCR panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the urine polymerase chain reaction (PCR) panel provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show you have chronic 
respiratory failure due to asthma and chronic obstructive pulmonary disease (COPD). The home ventilator is 
being requested for use in a volume assured pressure support (VAPS) mode which could be provided by a 
BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. Medicare does not 
cover a ventilator for this use. The services are not reasonable or medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature, with or without adjustability (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-
shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s (L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that additional information has been submitted to show 
why the enrollee needs the microprocessor knee over the mechanical without the knee, the enrollee will be at 
risk for further injury. The Plan denied your request. The Plan says that a prosthesis that meets but does not 
exceed the enrollee's needs can be provided. The requested prosthetic parts exceed the enrollee's needs. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no documentation that the enrollee meets the 
LCD criteria for approval of the microprocessor knee. Provided medical records from the enrollee's physician 
in this case do not clarify why a K3 mechanical knee would not meet his mobility needs, especially given his 
residence in an assisted living facility. The enrollee's only reported request with regard to the prosthesis is "I 
just want to walk." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an 
addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s (L5856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on September 28, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that the medical records support the billing of 
code 99222. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99222. 
 
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 99222 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 procedure code 99222. Our reviewer says that the medical 
records do not support the billing of code 99222. Our reviewer found the enrollee presented to the hospital with 
several days of malaise. She was noted to have atrial fibrillation with rapid ventricular response (RVR) based 
on electrocardiogram (ECG) findings and was admitted. ECHO showed mild aortic stenosis and left ventricular 
ejection fraction (LVEF) 40-55%, and cardioversion was planned. Vitals were stable except for heart rate of 
135. Workup rules out acute coronary syndrome (ACS), infection, and any other acute condition. History and 
examination were basic and focused without sufficient documentation to be considered comprehensive. Also, 
the presentation, workup, and treatment would not be considered of moderate complexity, but rather low 
complexity based on the provided documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 provided on September 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. 
The enrollees care needs can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier emergency department and/or observation care) would 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.