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

 
We decided that the Plan does not have to pre-approve 4 additional chiropractic manipulative treatments.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates the enrollee has a cervical and thoracic subluxation. The records of these visits do not support 
progressive improvement of symptoms but rather maintenance therapy. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested services. The 
elements of the coverage criteria are not satisfied. The requested services are not recommended.  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 4 additional chiropractic manipulative treatments.
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 medical records support the need for the SNF 
admission. The Plan denied your request. The Plan says the medical records indicate that the enrollees care can 
be met at a lower level of care.  
 
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. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J7999 billed for date of service March 1, 2023. 
 
You asked the Plan to pay for code J7999. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says code J7999 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that code J7999 has a status indicator of N on the Physician Fee Schedule. This means that procedure 
code J7999 is not payable. Based on this information, we decided that Medicare rules for coverage of code 
J7999 have not been met. Therefore, we decided that the Plan does not have to pay for code J7999 billed for 
date of service March 1, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 medically necessary. The Plan 
denied your request. The Plan says that you do not meet the criteria for admission to an IRF.  
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of your nursing, medical and rehabilitation requires an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. You require treatment by multiple therapies, including 
physical therapy and occupational therapy, 5 days a week for at least 3 hours. There is a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service March 13, 2022, 
to April 11, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 12, 2022. The NOA was not received by the Plan until May 9, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service March 13, 2022, to April 11, 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 this is the best option for the enrollee to receive 
extensive therapy services. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an 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 clinical documentation shows that the enrollee has had a clinical and functional 
status change that would be expected to require ongoing assessment by skilled nursing. The records received do 
not support the need for daily skilled services on an inpatient basis in a skilled nursing 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteoflow allograft. 
 
You asked the Plan to pre-approve an osteoflow allograft. You say that the enrollee has had little relief from 
conservative treatment. The Plan denied your request. The Plan says the clinical value and effectiveness of 
osteoflow allograft in the setting is spinal fusion surgery 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 an osteoflow allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found osteoflow allograft is considered experimental and more research is needed. An iliac 
crest autogenous bone graft is considered the gold standard.  
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 osteoflow allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an osteoflow allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Stimwave peripheral nerve stimulator (PNS) System. 
 
You asked the Plan to pre-approve the service. You say that the enrollee is not able to perform activities of 
daily living due to the pain. You say that the enrollee has tried many conservative treatment options with no 
success. You also say that this is necessary for the enrollee's health. The Plan denied your request. The Plan 
says this device 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of PNS for low back pain is the subject of ongoing clinical trials and is considered 
experimental for this diagnosis. Therefore, the request is deemed 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Stimwave peripheral nerve stimulator (PNS) System.
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 has palsy in right arm and shoulder, will 
not be able to regain the maximum function without the therapy. The Plan denied your request. The Plan says 
the enrollee does not meet the requirements for rehabilitation. Services needed may be provided safely in 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on November 29, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this is a 
duplicate claim. 
 
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. The Plan argues that there are two previous claims that have processed and paid 
with the same codes. However, the Plan has not provided documentation showing that a previous claim was 
processed and paid for the services at issue in this case. The Plan has not shown that this is a duplicate claim. 
Without supporting documentation, the Plans denial cannot be substantiated. Therefore, we decided that the 
Plan has to pay for the lab services provided on November 29, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from January 27, 2022, 
to January 28, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records confirm the presence of clinical evidence for J15.6, and they confirm hospital resources were 
used to treat this condition. You say that originally billed DRG is more accurate to the enrollee's condition and 
the provider was correct billing J15.6 as the principal diagnosis code. The Plan denied your request. The Plan 
says diagnosis code J15.6 is not supported, which resulted in a DRG change.  
 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code J15.6, defined as pneumonia due to other 
Gram-negative bacteria. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that diagnosis code J15.6 is not supported. 
Our physician reviewer found that the enrollee was found to have bilateral ground glass opacities on the 
computed tomography scan of the chest. The enrollee was treated for presumed pneumonia with ceftriaxone 
and Levaquin, but there is no documentation of an isolated gram-negative bacteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from January 27, 2022, to January 28, 2022, at the DRG originally 
billed.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Prolia. Our reviewer says that Prolia is 
medically reasonable and necessary for the enrollee. Our physician reviewer found that denosumab (Prolia) 
decreases bone resorption by inhibiting osteoclast activity. Denosumab was approved by the FDA in 2010 and 
shown benefit in cancer patients and patients with postmenopausal osteoporosis. The documentation supports 
that Prolia is safe and effective 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 Prolia have not been met. Therefore, we decided that the Plan has to pre-
approve Prolia (J0897).  
 
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 anesthesia for lower intestinal endoscopic procedures, 
endoscope introduced distal to duodenum; not otherwise specified (00811). 
 
You asked the Plan to pre-approve anesthesia. You say that the enrollee is having a colonoscopy and needs 
anesthesia. 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 anesthesia. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that this enrollee does not have a diagnosis, condition, and/or 
symptoms that meet the Medicare criteria for coverage of Monitored Anesthesia Care (MAC). In this case, the 
enrollee has no significant progressive macular hypomelanosis (PMH) to warrant MAC. There is no 
documentation in the enrollee's record indicating that it is medically necessary to have an anesthesiologist 
present during the colonoscopy. MAC is not considered the standard of care in the treatment of this enrollee's 
condition. During a screening colonoscopy for a healthy adult, the standard of practice is for the endoscopy 
nurse, under the guidance/ supervision of the physician, to monitor vital signs and pulse oximetry and 
administer sedation/analgesia, with medications (such as, Midazolam and Fentanyl). The review has 
determined that the monitored anesthesia care provided on August 2, 2023, was not medically reasonable or 
necessary for treatment of the enrollees screening colonoscopy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to 
duodenum; not otherwise specified (00811).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0482) provided on October 4, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says the code used to report the drug testing provided 
is not supported in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), 
including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the record shows that drugs 
from more than 21 drug classes were tested in this case. This means another code would more accurately report 
the services provided. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0482) 
provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 chiropractic manipulative treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has cervical spasms and radiculopathy.   
 
The records provided do not document the presence of a subluxation of the spine either by physical 
examination or radiographic images. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested services. The elements of the coverage criteria 
are not satisfied. The requested services are not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 6 chiropractic manipulative treatments.