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 the enrollee clearly exceeds the criteria for a 
medically appropriate acute IRF admission. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in 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 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 25, 2022, 
through July 24, 2022.  
 You asked the Plan to pay for the home health services. You say that an NOA was submitted timely, and all 
other requirements have been met. This claim should be paid.  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 June 25, 2022. The NOA was not received by the Plan. Though it is noted 
that an NOA was submitted, the provider did not submit evidence to prove that it was submitted and received 
by the Plan. 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 
provided from June 25, 2022, through July 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulator (TENS) device 
(E0730) provided September 20, 2022. 
 
You asked the Plan to pay for the TENS device. You say that you ask for reconsideration of the claim for 
payment or provide documentation to support the decision to deny. The Plan denied your request. The Plan 
says the request for a transcutaneous electrical nerve stimulation (TENS) device (E0730) does not meet 
Medicare rules.  
 
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 TENS device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare rules say that TENS is not reasonable and necessary for the treatment of Chronic low 
back pain (CLBP) under section 1862(a)(1)(A) of the Social Security Act; and TENS therapy for Chronic Low 
Back Pain will be denied as not reasonable and necessary. Medicare only allows special coverage for TENS for 
CLBP when the patient is enrolled in an approved clinical study under coverage with evidence development 
(CED) and is registered on the ClinicalTrials.gov website by the principal sponsor/investigator. The medical 
records do not indicate the member is enrolled in an approved clinical study. 
 
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 TENS device have not been met. Therefore, we decided that the Plan does 
not have to pay for a transcutaneous electrical nerve stimulator (TENS) device (E0730) provided September 
20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the procedure provided on August 29, 2022. 
 
You asked the Plan to pay for the procedure. The Plan denied your request. The Plan says that the operative 
report does not document that the servicing provider performed this procedure. 
 
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 records show that the servicing provider was the surgical assistant in this 
case, and the provider is claiming that this person provided the services. The Plan has not provided 
documentation supporting its denial. Therefore, we decided that the Plan has to pay for the procedure provided 
on August 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: 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 the enrollee requires more therapy because they are 
bed bound and in pain. The Plan denied your request. The Plan says the request is not medically necessary.   
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 that 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 or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says that it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that left heart catheterization may be covered under 
certain circumstances. 
 
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 heart catheterization. Our reviewer says 
that at this time, cardiac catheterization would not be considered medically appropriate and necessary in this 
patients clinical management. Our physician reviewer found that the enrollee had a negative radionuclide 
stress test. Documentation does not reveal the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this 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 heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left cardiac catheterization.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the documentation supports a need for 
medical necessary. You also say that this procedure is not experimental and investigational. The Plan denied 
your request. The Plan says this service is considered experimental /investivational and therefore is 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found additional study is needed to validate any benefit of the procedure, and to compare it to other interventions. Current medical literature indicates that the Intracept procedure is investigational at this 
time. Therefore, the reviewer found that the requested Intracept procedure is not medically 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that the enrollee had 
computed tomography (CT) of the abdomen in 2016, which showed a 0.7 x 1.0 cm mesenteric structure which 
has increased in size on a recent computed tomography angiography (CTA) study. The request for a dedicated 
CT abdomen and pelvis has been denied as medically unnecessary. The comparison study of 6/27/23 was a 
CTA of the chest, abdomen and pelvis for possible dissection and was not a dedicated CT of the abdomen and 
pelvis. Due to the apparent mild increase in size of a mesenteric structure over 7 years time a CT of the 
abdomen and pelvis is reasonable and should be approved to determine if CT guided biopsy will be necessary 
or other surveillance. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the abdomen and pelvis.  
 
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 pay for an office visit (procedure code 99213) rendered on August 
31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support the 
separate reporting of CPT 99213-25. The procedure is the reason for the visit, and any evaluation done was in 
preparation of the planned procedure. Modifier -25 is not verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (procedure code 99213) rendered on August 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluorouracil, leucovorin, trastuzumab-anns and 
oxaliplatin. 
 
You asked the Plan to pre-approve the drugs. You say that the requested drugs are medically necessary. The 
Plan denied your request. The Plan says the requested use of this drug combination is not supported.  
 
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 the drugs. Our reviewer says that the 
requested drug combination is not supported. Our physician reviewer found The Food and Drug Administration 
has not stated that the requested drug regimen is indicated for the enrollee's specific condition. The requested 
drug regimen is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve fluorouracil, leucovorin, trastuzumab-anns and oxaliplatin.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided July 11, 2021, to July 13, 
2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that these services could have been provided under 
observation care. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee's condition did not stabilize until July 13, 2023. 
 
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 has to pay for the acute inpatient hospital care provided July 11, 2021, to July 13, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan with computed 
tomography (CT) for attenuation. 
 
You asked the Plan to pay for the services. You say that the nodules are possibly cancerous, and the enrollee 
needs to follow up with the imaging. The Plan denied your request. The Plan says this cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 pay for the services. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the enrollee has no 
known malignancy. Computed tomography angiography (CTA) from 6/27/23 was compared to a CT of the 
abdomen of 11/19/16, which showed a mesenteric node having slightly increased in size over a course of 7 
years from 0.7x1.0 cm to a current size of 0.9x1.4 cm. The likelihood of malignancy was described as low. The 
medical necessity of the requested PET/CT has not been established in the submitted records.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a positron emission tomography (PET) scan with computed tomography (CT) for attenuation.
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 feel, as your team of doctors do, that you would 
benefit from acute rehabilitation. You say you also feel you would not be able to regain your full level of 
independence in a skilled nursing facility as you would with more intense therapy. The Plan denied your 
request. The Plan says it is not necessary for you to be admitted into an acute IRF at this time.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued inpatient psychiatric admission from 
August 11, 2023, forward.  
 
You asked the Plan to pre-approve the continued inpatient psychiatric admission. You say that the enrollee has 
a history of dementia has been agitated refusing meals at home, is not sleeping and is aggressive toward family.  
The Plan denied your request. The Plan says at this time your records do not show that the enrollee is exhibiting dangerous behaviors, is unable to function at a lower level of care, has serious medication side 
effects, or has a substance abuse problem.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric 
admission. Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
based upon review the records provided for the admission of this enrollee does not meet the criteria for August 
11, 2023, forward as this enrollee was not shown to be a danger to self or others, delusions, auditory or visual 
hallucinations noted. The enrollee was cooperative/compliant with treatment while not showing any threats the 
safety. 
 
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 continued inpatient psychiatric admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continued inpatient psychiatric admission from August 
11, 2023, forward.