Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this admission is medically 
necessary. The Plan denied your request. The Plan says that an inpatient admission is not medically necessary 
for the enrollee's treatment. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee presented with complaints of myalgias, sore throat, chills with 
sweats and cough. The enrollee was hypotensive and was treated with intravenous fluids and antibiotics for 
presumed pneumonia. After admission, the enrollees condition stabilized and improved with medical therapy. 
The review has determined that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pre-approve an acute inpatient hospital admission.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 10, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says this claim does not meet the 
requirements for non-emergency transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance transport was not medically necessary. Our physician reviewer found the transportation via 
ambulance from the doctor's office to the  enrollee's assisted living facility was not medically necessary. The 
enrollee was not bedbound, as noted to be ambulatory.  The enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport.  
Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. 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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support the need for 
IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility (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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for seizure and aspiration pneumonia. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. While the medical records support 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says this 
request does not meet Medicare guidelines because the enrollee no longer requires skilled services on a daily 
inpatient basis and the continuation of SNF 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. Our reviewer also found that the enrollee does not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician office visits (99203, 99213) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve physician office visits. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for OON services have not 
been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physician office visits (99203, 99213) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing provided on October 21, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was not 
billed with the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the claim was not billed with the appropriate DEX Z-code. 
However, the submitted claim form was billed with DEX Z-code ZBBLD. The Plan has not provided 
documentation showing that this code is inappropriate for the services billed in this case. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
testing provided on October 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve block is 
experimental/investigational. 
 
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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary. Our 
physician reviewer found that the role of genicular nerve blocks after total knee arthroplasty is the subject of 
ongoing clinical trials and is considered experimental at this time. Therefore, the request is deemed not 
medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items/accessories (codes E1007, E1012, E2359, E1028, E2300, E0953, 
E2620, E2624, E2311, E2313, E2377, K0108, and K0108). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power options and 
additional items/accessories. You say that you have a form of Parkinson's disease, and you have lost your 
ability to walk. You also say that you have to be transferred everywhere you go by a lift, and a power 
wheelchair would make your life a little easier. The Plan denied your request. The Plan says you do not have 
medical need for multiple power options available with a K0861 Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (MRADLs), the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the 
patient is not capable of safely operating the requested PMD. 
 
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 a Group 3 standard power wheelchair 
with multiple power options and additional items/accessories. Our reviewer says that a Group 3 power 
wheelchair with multiple power options is not medically necessary. Our physician reviewer found you do have 
a Group 3 qualifying neurologic diagnosis, but the documentation does not reveal that your needs are at high 
risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs 
a power seating system to manage increased tone or spasticity. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 standard power wheelchair with multiple power options and 
additional items/accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 standard power wheelchair with multiple power options (K0861) and additional 
items/accessories (codes E1007, E1012, E2359, E1028, E2300, E0953, E2620, E2624, E2311, E2313, E2377, 
K0108, and K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug testing (80305) to be provided by a provider not 
contracted with the Plan to provide laboratory-testing services. 
 
You asked the Plan to pre-approve drug testing. You say that the requested service is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for out-of-network services have not been 
met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
drug testing (80305) to be provided by a provider not contracted with the Plan to provide laboratory-testing 
services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve cryoablation (64624), provided on 
November 1, 2022. 
 
You asked the Plan to pay for the genicular nerve cryoablation. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genicular nerve cryoablation. Our 
reviewer says that the requested service is  not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered experimental. 
 
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 genicular nerve cryoablation have not been met. Therefore, we decided that 
the Plan does not have to pay for the genicular nerve cryoablation (64624), provided on November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests should be included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging with single photon emission 
computed tomography (SPECT) (78071). 
 
You asked the Plan to pre-approve parathyroid planar imaging. You say that you want to appeal this denial. 
The Plan denied your request. The Plan says the provided documentation does not show that the enrollee has 
elevated parathyroid and calcium levels. 
 
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 parathyroid planar imaging. Our 
reviewer says that the requested parathyroid planar imaging is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation does not indicate why the 
requested imaging is needed. Therefore, the reviewer found that the parathyroid planar imaging is 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 parathyroid planar imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve parathyroid planar imaging with single photon emission computed 
tomography (SPECT) (78071).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 30, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on October 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous sacroplasty services. 
 
You asked the Plan to pre-approve percutaneous sacroplasty services. You say that the clinical information 
provided supports the need for the services in dispute. The Plan denied your request. The Plan says 
percutaneous sacroplasty is considered to be unproven and medically unnecessary due to insufficient evidence 
of efficacy. 
 
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 percutaneous sacroplasty services. Our 
reviewer says that percutaneous sacroplasty services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, 
reasonable, comprehensive, less invasive conservative care measures directed to the sacrum is not evident. Additionally, the provided objective exam findings revealed pain in the far-right lateral soft tissue with 
palpation. Strength and sensation are intact. Range of motion of the right hip does not reproduce pain. The 
updated imaging, including the February 12, 2023, computed tomography and the April 12, 2023, magnetic 
resonance imaging of the lumbar spine, demonstrated fluid collection on the right-sided soft tissue that was 
opined to be a likely seroma.  The documentation does not rule this finding out as a potential cause of post-
operative right-sided pain. There are limited large-scale, long-term references showing the safety and efficacy 
of the requested surgery in this clinical setting. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 sacroplasty services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous sacroplasty services.