Persius/hicric huggingface dataset:
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 your husband and providers at the hospital where 
you currently are feel like you will need more consistent care than home health can offer. The Plan denied your 
request. The Plan says based on the available information, admission to an IRF is not reasonable and 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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our 
reviewer also found that your care needs can be met 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current 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 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 they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.  
 
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: 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 medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee does not have 
clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
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 has ongoing acute medical issues and 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. The elements 
of the coverage rules are not satisfied. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits, the outpatient clinic visit, and the inpatient 
admission provided on February 10, 2022, to November 07, 2022. 
 
You asked the Plan to pay for the office visits, the outpatient clinic visit, and the inpatient admission. You say 
that you are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visits, the 
outpatient clinic visit, and the inpatient admission provided on February 10, 2022, to November 07, 2022.
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 medically necessary for the enrollee 
to receive the care needed to return to prior level of function. The Plan denied your request. The Plan says this 
request does not meet Medicare guidelines for medical necessity because the enrollee's medical condition 
requires 
further evaluation and treatment in the acute care hospital  
 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 the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met 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 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 additional moderate sedation time provided on date of 
service May 22, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service May 22, 2023, billed with 
code 99153.
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. The Plan denied your request. The Plan says criteria 
for admission to the LTACH have not been met. 
 
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 weakness and urinary incontinence and 
found to have pneumonitis secondary to dysphagia and aspiration. The record indicates that the enrollee has 
ongoing acute medical issues and still requires acute care services before transitioning to a lower level of care. 
Our reviewer found that the enrollee continues to receive acute care services, and these have not been denied. 
Our physician reviewer also found that the medical record does not indicate that the enrollee requires services 
that they are not currently receiving but 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for The portable x-ray services coded as 71046-TC, R0070, and 
Q0092 billed on date of service March 30, 2023. 
 
You asked the Plan to pay for the portable x-ray services. You say that the portable x-ray services should be 
paid as billed because they are supported in the documentation. The Plan denied your request. The Plan says 
the portable x-ray services are denied because they were performed while the enrollee was in a covered SNF 
stay, so they are included in the SNF PPS (Prospective Payment System) rate. 
 The Plan must follow Medicare rules. Medicare rules say that when a SNF resident receives a portable x-ray 
service, only the service's professional component is a separately billable physican service under Part B. 
 
We looked at the file and Medicare rules. We confirmed that codes R0070, defined as transportation of portable 
x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen, and 
Q0092, defined as set-up portable x-ray equipment, have a professional component (PC)/technical component 
(TC) flag of 3. This indicator identifies stand-alone codes that describe the technical component (for example, 
staff and equipment costs) of selected diagnostic tests only. We confirmed that in this case, code 71046 was 
billed with modifier -TC, also indicating the technical component only. According to Medicare rules, when an 
enrollee receives a portable x-ray service during the course of a Part A covered SNF stay, the technical 
component of a procedure, including any associated transportation and set up costs, must be included on the 
SNF's Part A bill for the enrollee's covered stay. The technical component is not separately billable by the 
physican under Part B. Based on this information, we decided that Medicare rules for coverage of the portable 
x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for The portable x-
ray services coded as 71046-TC, R0070, and Q0092 billed on date of service March 30, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 You asked the Plan to pre-approve Neulasta. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Neulasta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects 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 Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine. The notes do not show 
that the enrollee has complex care needs that require a coordinated team approach. The notes do not show that 
the enrollee must have he notes do not show that the member's care specifically requires the involvement of a doctor in the field of Rehabilitation Medicine. The notes do not show that the enrollee has complex care 
needs that require a coordinated team approach. The notes do not show that the enrollee must have an intensive 
therapy program (3 hours a day, at least 5 days a week) in order to improve self-care functioning.  
 
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 is medically improving and stable, and does not need a physical 
medicine and rehabilitation physician's supervision 3 times a week in an IRF. No acute rehabilitation nursing 
needs documented. At the current functional level, the enrollee needs physical therapy and occupational 
therapy and does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days 
per week with a multidisciplinary approach in an IRF. The documentation does not support the necessity for 
admission to an IRF. The complexity of the enrollee's medical, rehabilitation, and nursing needs  does not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. 
The enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnioid DASH. 
 
You asked the Plan to pre-approve Omnioid DASH. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps are non-covered devices because they do not meet the Medicare definition of 
durable medical equipment. 
 
We looked at the file and Medicare rules. Review of the file shows that the item at issue is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of Omnioid DASH have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Omnioid DASH.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).  
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. 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 follows Medicare rules. Medicare rules say that an ultrasonic osteogenesis stimulator (E0760) is 
covered only if all criteria are 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 an ultrasonic osteogenesis stimulator. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the ultrasonic osteogenesis stimulator at issue in this 
case meets all Medicare and LCD criteria for medically reasonable and necessary for the enrollee. Provided 
records in this case do not document nonunion of a fracture documented by a minimum of two sets of 
radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 
days showing no clinically significant evidence of fracture healing between the two sets of radiographs as 
required by the LCD. 
 
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 ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 22, 2023, billed with 
codes 81306, 81328, 81335, 81350, 81400, 81401, 81406, 81479, 81220, 81225, 81226, 81227, 81230, 81231, 
81232, 81240, 81241, 81291, 81247, 81291, 81247, 81283, 81355, 81381. 
 
You asked the Plan to pay for the genetic testing billed. You say that you performed the testing services that 
were specifically requested by the enrollee's physician. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 22, 2023, billed with codes 81306, 81328, 81335, 81350, 81400, 81401, 81406, 81479, 81220, 81225, 
81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81247, 81291, 81247, 81283, 81355, 81381.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 29, 2023, to May 
11, 2023. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the NOA was not received. 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 NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from March 29, 
2023, to May 11, 2023.
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 enrollee will require an LTACH level 
of care, clearly meets the LTACH criteria based on Medicare guidelines, and is currently stable for discharge. 
The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 acute on chronic systolic heart failure 
complicated by acute on chronic respiratory failure. The record indicates that the enrollee is improving but still 
requires acute care services before transitioning to a lower level of care. Our reviewer found that the enrollee 
continues to receive acute care services, and these have not been denied. Our physician reviewer also found 
that the medical record does not indicate that the enrollee requires services that they are not currently receiving 
but 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.