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 still requires extensive assistance to 
complete daily tasks. The Plan denied your request. The Plan says the IRF services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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's 
medical problems are stable and 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 this patient 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 VIA disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve VIA disc allograft intervertebral disc augmentation procedure. You say that 
you are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the 
requested service is not supported by research and 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 VIA disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found VIA disc allograft is experimental for 
degenerative back pain. More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve VIA disc allograft intervertebral disc 
augmentation procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve solid organ or hematolymphoid neoplasm or disorder, 
51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number 
variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA (81455). 
 You asked the Plan to pre-approve solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, 
genomic sequence analysis panel. 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 genetic testing is covered when specific 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 solid organ or hematolymphoid 
neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case. the review indicates that 
records do not show that the specific test ordered has FDA approval per review of the FDA website on 
December 28, 2023. FDA approval is required by the NCD. The review has determined that the enrollee does 
not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, 
genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pre-
approve solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis 
panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression 
or mRNA expression levels, if performed; DNA (81455).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix skin substitute (Q4186). 
 
You asked the Plan to pre-approve Epifix. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 Epifix. 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 the documentation submitted does not show that the enrollee is 
diabetic, and the wound is not a diabetic wound. The requested product is therefore considered investigational 
in the treatment of this chronic ulcer of the left heel. The review has determined that the items/services at issue in this case are not medically reasonable or 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 Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix skin substitute (Q4186).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the requested service 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve block is experimental for 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service June 26, 2023, to July 
25, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the NOA 
was not submitted timely. 
 
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. 
 
We looked at the file and the rules. The appeal includes documentation that a valid NOA was billed on March 
29, 2023, which is within 5 calendar days from the start of care date, March 28, 2023. The Plan has not 
provided any documentation to show that a valid NOA was not received timely. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for the home health care billed for dates of service June 
26, 2023, to July 25, 2023.  
 
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 the screening digital breast tomosynthesis and screening 
mammography (Mammogram) billed with codes 77063 and 77067 provided on August 15, 2023. 
 
You asked the Plan to pay for the mammogram screening. You say that the services were billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 8, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the mammogram screening have not been 
met. Therefore, we decided that the Plan does not have to pay for the screening digital breast tomosynthesis 
and screening mammography (Mammogram) billed with codes 77063 and 77067 provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous vertebral augmentation (PVA) for osteoporotic 
vertebral compression fracture (VCF). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation (PVA) for osteoporotic vertebral 
compression fracture (VCF). You say that you are requesting reconsideration for the denied claim. The Plan 
denied your request. The Plan says that it is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 percutaneous vertebral augmentation 
(PVA) for osteoporotic vertebral compression fracture (VCF). Our reviewer says that the requested 
items/services are considered medically reasonable and necessary in this case. Our physician reviewer found 
The T11 and T12 compression fractures involve at lease a 25% loss in height of the vertebral bodies thus 
qualifying each level for percutaneous vertebroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation (PVA) for osteoporotic vertebral 
compression fracture (VCF) have been met. Therefore, we decided that the Plan has to pre-approve 
percutaneous vertebral augmentation (PVA) for osteoporotic vertebral compression fracture (VCF).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission for robotic assisted laparoscopic repair 
of paraoesophageal hernia with or without mesh, fundoplication and esophagastroduodenoscopy (EGD). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the preoperative clearance and comorbid conditions suggest that the 
procedure could initially be performed on an ambulatory/observation basis. 
 
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 requested inpatient level of care is not medically reasonable or necessary.Our physician reviewer 
found that the enrollee is to undergo an elective robotic-assisted, laparoscopic paraesophageal hernia repair (+/- 
mesh), fundoplication, and esophagogastroduodenoscopy. The operation has been approved but the inpatient 
stay has not been approved. The enrollee's past history is significant for acid reflux, anxiety, arthritis, 
osteoporosis, depression, and cataracts. None of her prior surgeries complicate the proposed surgery or put it at 
higher risk for complications (e.g., catarat surgery, right hip arthroplasty, tonsilectomy, etc.). There is no 
documentation to suggest an inpatient admission is 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient admission for robotic assisted laparoscopic repair of paraoesophageal 
hernia with or without mesh, fundoplication and esophagastroduodenoscopy (EGD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 20, 2023, billed with 
procedure codes 99203-25 and 99152. 
 
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 99203-25 and 99152 is inpatient consultation for a new 
or established patient, which requires these 3 key components: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity, and moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
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 in this case, CPT 99203 is being 
billed incorrectly. A more appropriate code would be CPT 99255.  Code 99152 remains not supported. The 
submitted medical records don't indicate the presence of an independent trained observer for the billed services. 
 
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 July 20, 2023, billed with procedure codes 
99203-25 and 99152.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that the transportation is 
necessary for dialysis treatment. The Plan denied your request. The Plan says the routine transportation benefit 
has been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation 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 you are appealing the denial. The Plan 
denied your request. The Plan says that you can safely receive the required care in another 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 that per the documentation received, the plan is not to decannulate you; therefore, no 
further weaning is indicated. You do not have complex wound care. You do not meet LTACH admission 
criteria. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency medical services provided April 17, 2023. 
 
You asked the Plan to pay for the emergency medical services. You say that $780 is not what you paid at the 
hospital. You state it is about $5,000 and you need the rest of the money. The Plan denied your request. The 
Plan says the claim was paid on September 7, 2023, issuing a reimbursement to you in the amount of $780. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Review of the file shows that the Plan paid $780 for the services 
you received on April 17, 2023. You were asked to pay a $120 copayment for the services you received. 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 pay for the emergency medical services provided April 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided August 
24, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that the services provided 
should be covered. 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 $150 
copayment for other Medicare-covered radiological diagnostic services, including ultrasounds. 
 
You have been asked to pay $105.08, which is less than the standard copayment for the abdominal ultrasound. 
This item/service falls within the outpatient diagnostic tests and therapeutic services benefit category. 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 waive the copayment for the abdominal ultrasound provided August 24, 2023.