Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services.  
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied claim and feel that the services requested are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy 
needs. As such, home health care is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing 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 the enrollee requires IRF services in order to return 
home at their maximum level of functioning with a decreased risk for readmission. The Plan denied your 
request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 the enrollee's clinical condition meets full inpatient 
acute rehabilitation criteria and a lower level of care in skilled nursing cannot provide total interdisciplinary 
approach needed with therapists specially trained in rehabilitation and would extend the time to return home. 
The Plan denied your request. The Plan says the enrollee's records do not show the need for an intensive team 
for care.  The Plan says that the services needed may be provided safely in a lower level of care.  
 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.  
 
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 pre-approve home health physical therapy. 
 You asked the Plan to pre-approve home health services. You say that you are appealing the Plan's denial. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have skilled physical therapy (PT) needs. The enrollee is not shown to have an acute illness or injury. 
The enrollee is not shown to be able to partake in skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 10, 2022, billed with 
codes 81295, 81298, 81301, 81311, 81272, 81275, 81275, 81292, 81191, 81317, 81321, 81210, 81191 and 
81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 
January 10, 2022, billed with codes 81295, 81298, 81301, 81311, 81272, 81275, 81275, 81292, 81191, 81317, 
81321, 81210, 81191 and 81317.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
September 16, 2022, to September 29, 2022, at the Patient Driven Payment Model (PDPM) rate billed. 
 
You asked the Plan to pay for the SNF services as billed. You say that this was billed correctly.  The Plan 
denied your request. The Plan says the active diagnoses reported are not all supported as required in the 
records.  
 
The Plan follows Medicare rules. Medicare rules say that SNF services are paid based on a HIPPS code that is 
calculated in part by the enrollee's active diagnoses.  
 
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 SNF services as billed. Our reviewer 
says that the active diagnoses listed are not supported by the documentation.  Our physician reviewer found 
although provided therapy records document a history of a T12 vertebroplasty and diabetes mellitus, no 
physician authored or signed documentation is presented which confirms these diagnoses as required by the 
Centers for Medicare and Medicaid Services rules. 
 
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 SNF services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for skilled nursing facility (SNF) services provided from September 16, 2022, to 
September 29, 2022, at the Patient Driven Payment Model (PDPM) rate billed.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Leqembi treatments.  
 
You asked the Plan to pay for the Leqembi. You say that this is covered by Medicare when the enrollee's data 
is provided to an approved clinical registry. The enrollee will be participating in this registry.  The Plan denied 
your request. The Plan says that the enrollee is not participating in an approved trial.  
 
The Plan must follow Medicare rules. Medicare rules say that monoclonal antibodies for the treatment of AD 
may be covered under Coverage with Evidence Development (CED), requiring participation in a study.  
 
We looked at the file and Medicare rules. The treating physician clearly indicates that the enrollee will be 
participating in an approved clinical registry listed on the CMS website. Based on this information, we decided 
that Medicare rules for coverage of the Leqembi have not been met. Therefore, we decided that the Plan has to 
pay for Leqembi treatments.   
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Faserna. 
 
You asked the Plan to pre-approve Faserna. You say that the services are medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Faserna.  Benefits for Faserna may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that you are not requesting custodial care for 
coverage for meals to be delivered, shopping, cleaning, laundry services, bathing, dressing or toileting. You say 
that your doctor will not perform knee surgery unless you have a home health aide. The Plan denied your 
request. The Plan says the services are custodial care.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found no medical notes 
from your treating physician are provided documenting a current order or need for skilled home health services. 
As skilled home health nursing and therapy services are not being provided, home health aide services are not 
covered by Medicare.  
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that continued care is medically necessary. The Plan 
denied your request. The Plan says the services are no longer 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76942 billed for date of service March 13, 2023. 
 
You asked the Plan to pay for procedure code 76942. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says that the payment for code 76942 is included in the 
payment for code 64447. 
 
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. Specifically, we were unable to verify any NCCI edit between code 76942 and 
any other code billed on this claim. The Plan has not provided a reason for denial which is supported by 
evidence and Medicare rules. Therefore, we decided that the Plan has to pay for procedure code 76942 billed 
for date of service March 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous (IV) insulin therapy (OIVIT) 
services provided on April 27, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. 
 
We looked at the file and Medicare rules. Per Medicare rules, the requested OIVIT services are not medically reasonable and necessary, and therefore are not covered. 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 the outpatient intravenous (IV) insulin therapy (OIVIT) services provided on April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4930 billed for date of service January 15, 2022.  
 You asked the Plan to pay for code A4930. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code A4930 is 0. The MAI value for this code is 3. You billed 1 unit of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4930 have not been met. Therefore, we decided that the 
Plan does not have to pay for code A4930 billed for date of service January 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service May 4, 2023.  
 You asked the Plan to pay for procedure code 99223. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99223 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99223 billed for date of service May 4, 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 is having problems with 
thinking and acting. The Plan denied your request. The Plan says the enrollee is not well enough to leave the 
current hospital. 
 
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 enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal facet joint radiofrequency ablation (RFA) 
procedure of the facet joints. 
 
You asked the Plan to pre-approve the facet joint RFA procedure. You say that the enrollee is in extreme pain 
and needs something else to relieve pain other than increasing opioids. The Plan denied your request. The Plan 
says the thermal facet joint radiofrequency ablation procedures are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the use of RFA of the facet joints requires at least two 
diagnostic facet joint injections, MBBs, which provide at least 80% pain relief.  
 
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 facet joint RFA procedure. Our 
reviewer says that the coverage criteria for this procedure are not met.  Our physician reviewer found detailed 
documentation regarding at least two (2) medically reasonable and necessary diagnostic MBBs at the requested 
RFA levels, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain 
(with the duration of relief being consistent with the agent used) is not evident. She is noted to have had one on the right side and one on the left side. The request is being made for separate procedures (left side followed by 
the right side). Additionally, the requested procedure is at more than one to two levels as the request is for L3-
S1. The formal imaging study was not provided to corroborate facet pathology at all of the requested levels. 
Moreover, there are other plausible causes of pain including radicular findings noted on the July 5, 2023, exam 
(decreased strength, deep tendon reflexes, and sensation in the lower extremities). Therefore, the enrollee does 
not meet the criteria for the ablation procedures. 
 
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 facet joint RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the thermal facet joint radiofrequency ablation (RFA) procedure of the facet 
joints.