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

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections and procedures. 
 
You asked the Plan to pre-approve sacroiliac joint injections and procedures. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that SJI is covered when the criteria listed in the Medicare 
rules section is met. 
 
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 sacroiliac joint injections and 
procedures. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has other probable pain generators and needs documentation of 2 other SI joint diagnostic maneuvers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injections and procedures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint injections and procedures.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 31, 2022, billed with 
procedure codes 30117-LT-22, 31239-LT-22, and 31259-LT-22. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 30117-LT-22, 31239-LT-22, and 31259-LT-22 is 
excision or destruction (eg, laser), intranasal lesion; internal approach, nasal/sinus endoscopy, surgical; with 
dacryocystorhinostomy, and nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), 
including sphenoidotomy, with removal of tissue from the sphenoid sinus. 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the procedures cannot be verified, as 
they were not found documented in the operative report. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 31, 2022, billed with procedure codes 
30117-LT-22, 31239-LT-22, and 31259-LT-22.
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 you are requesting reconsideration for the denial of 
inpatient rehabilitation services. The Plan denied your request. The Plan says you do not meet the medical 
necessity criteria for an IRF admission.  
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gynecology services described by codes 56515 and 
57065 performed on April 26, 2023. 
 
You asked the Plan to pay for 56515 and 57065. You say that 56515 and 57065 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 56515 and 
57065 are denied because they are not supported in the documentation. 
 
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 56515 is destruction of lesion(s), vulva; extensive (for 
example, laser surgery, electrosurgery, cryosurgery, chemosurgery). 
 The CPT Code Manual definition of code 57065 is destruction of vaginal lesion(s); extensive (for example, 
laser surgery, electrosurgery, cryosurgery, chemosurgery). 
 
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 56515 and 57065. Our reviewer says that 56515 and 57065 
are not supported in the documentation. Our reviewer found that the procedure reports for 56515 and 57065 do 
not include sufficient documentation to support extensive lesion destruction. The procedure reports only 
document that treatment was performed on the entire vagina and on the entire vulva and introitus. Generally, 
for extensive lesion destruction, more than three lesions should be documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 56515 and 57065 have not been met. Therefore, we decided that the Plan does 
not have to pay for the gynecology services described by codes 56515 and 57065 performed on April 26, 2023.
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 requires therapy provided at an IRF 
level of care. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim Neo system. 
 
You asked the Plan to pre-approve Barostim NEO system. You say that the procedure is FDA-approved and 
medically necessary to treat the enrollee. The Plan denied your request. The Plan says the procedure requested 
does not meet the requirements for approval. 
 
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 Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Barostim Neo system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the application of a multi-layer 
compression system and the occupational therapy visits provided from August 8, 2023, to August 30, 2023.  
You asked the Plan to reduce copayments for the application of the compression systems as well as the 
copayments for the outpatient therapy visits. You say that these services were not provided therefore, youre 
requesting a review for this claim. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each Medicare-covered occupational therapy visit. You have also been asked to pay a $275 
copayment for each Medicare-covered application of the multi-layer compression systems. 
 
You have been asked to pay a total of $2,259.90 ($275 copayment + $1,984.90 copayment = $2,259.90) for the 
application of a compression system and outpatient therapy visits. This item/service falls within the outpatient 
rehabilitation services and outpatient surgery benefit category. You have been asked to pay $275, which is a 
$25 copayment for each occupational therapy visit ($25 copayment x 11 visits = $275). These services fall 
within the outpatient rehabilitation services benefit category. You have also been asked to pay $1,984.90, 
which is less than the standard copayment for each application of a multi-layer compression system ($198.49 
copayment x 10 visits = $1,984.90). These services fall within the outpatient surgery benefit category. You 
have been asked to pay a total of $2,259.90 ($275 copayment + $1,984.90 copayment = $2,259.90). This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayments the application of a multi-layer compression system and the 
occupational therapy visits provided from August 8, 2023, to August 30, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve JAK2 (JANUS KINASE 2) V617F gene mutation analysis panel 
genetic testing (81270). 
 
You asked the Plan to pre-approve the genetic testing. You say that you were referred by your primary nurse 
practitioner after they noted an elevated platelet count for your annual physician in August. The Plan denied 
your request. The Plan says that this service does not meet the criteria for medical necessity. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has thrombocytosis with platelets in 460,000-475,000/microliter.  The 
physician is recommending testing for essential thrombocytosis/thrombocythemia. The World Health 
Organization (WHO) diagnostic criteria for essential thrombocythemia is as follows: "essential thrombocytosis 
can be diagnosed when the platelet count is over 45,0000/microliter, and there is either a Janus kinase 2 
(JAK2), Calreticulin (CALR) or myeloproliferative leukemia virus oncogene (MPL) mutation, lacking clonal 
or reactive cause.  Given that the platelet count is above 450,000 and meets both of the criteria for JAK2 
V617F mutation above, this meets criteria for coverage. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan has to 
pre-approve JAK2 (JANUS KINASE 2) V617F gene mutation analysis panel genetic testing (81270).  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the 
established criteria for an LTACH admission. The Plan denied your request. The Plan says they will continue 
to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable 
for transfer to an alternate level of care (such as a skilled nursing facility), or until the clinical circumstances 
change such that LTACH may be reconsidered. 
 
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 in this case the enrollee was admitted with small bowel obstruction and required operative intervention. The record indicates that the enrollee has ongoing acute medical issues and still requires 
acute care services. 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 she is not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested 
service cannot be 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: 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 you deserve this chance in maximizing your 
condition in an attempt at having a better quality of life and returned to your prior level of functioning. The 
Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs can be met at a 
lower level of care such as a skilled nursing 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 you were admitted for surgical repair of a hip fracture. You medical problems are 
stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/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 enrollee is experiencing cognitive deficits such as 
impaired safety awareness, decreased awareness of errors and deficits, and decreased short-term memory.  He 
remains limited by decreased strength, endurance and balance. The Plan denied your request. The Plan says 
that admission to an IRF is not medically necessary and does not meet the criteria for coverage.  
 
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. The enrollee 
was admitted for carotid endarterectomy. There are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an iovera procedure. 
 
You asked the Plan to pre-approve the iovera procedure. You say that the enrollee is in severe pain and requires 
this procedure to regain the ability to do everyday activities. The Plan denied your request. The Plan says 
experimental and investigational procedures are not covered. 
 
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 iovera procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the iovera technology is considered experimental/investigational and is not 
medically necessary for the treatment of chronic knee pain. 
 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 iovera procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an iovera procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve KEYTRUDA. 
 
You asked the Plan to pre-approve KEYTRUDA. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the service is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 KEYTRUDA. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the use of KEYTRUDA is not FDA-
approved for the enrollee's diagnosis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of KEYTRUDA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve KEYTRUDA.