Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insert of a spine fixation device (22840), Arthrodesis 
(22633), Bone marrow aspiration (20939), and Posterior extradural 
laminotomy. 
 
You asked the Plan to pre-approve the insert of a spine fixation device. You say that you need this procedure. 
The Plan denied your request. The Plan says the requested procedure 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 pre-approve the insert of a spine fixation device. 
Our reviewer says that the requested items/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 is not evident. Moreover, dynamic flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at 
the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical 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 the insert of a spine fixation device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insert of a spine fixation device (22840), Arthrodesis (22633), 
Bone marrow aspiration (20939), and Posterior extradural 
laminotomy.
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 the enrollee needs to be assessed both medically and 
functionally in regard to their functional capacity to determine whether to benefit from a rehabilitation level of 
care. The Plan denied your request. The Plan says the records does not meet Medicare guidelines because the 
enrollee no longer requires skilled services on a daily inpatient basis. Services needed may be provided safely 
in a lower level of care. 
 
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 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 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESI). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that it is medically necessary. The Plan 
denied your request. The Plan says the doctor cancelled the procedure therefore injections aren't medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documentations at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale for at least three months. 
 
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 epidural steroid injections. Our 
reviewer says that the service is not medically necessary.  
 Our physician reviewer found the most recent epidural steroid injection March 23, 2023, provided 50% pain 
relief for a period of 10 weeks. The review has determined that the enrollee does not meet the coverage criteria 
for a repeat procedure. The enrollee does not meet any of the limitations/exclusions for this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (ESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary.  
The Plan denied your request. The Plan says you do 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinary tract infection (UTI) panel (87481, 87640, 87653 and 
87798) provided on September 30, 2022. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the records show that this testing was 
performed with a single qualitative real-time polymerase chain reaction (PCR) test kit. Therefore, we decided 
that the Plan does not have to pay for urinary tract infection (UTI) panel (87481, 87640, 87653 and 87798) 
provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on November 21, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested on the date of service in question. 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 drug testing services (G0482) provided on November 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from May 1, 
2022, to May 13, 2022. 
 
You asked the Plan to pay for the services. You say that you submitted supporting documentation for 
reconsideration of DRG adjustment. The Plan denied your request. The Plan says the provider has reported 
skilled services with the incorrect PDPM Health Insurance Prospective Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 based on the medical records 
provided there is no documentation by a physician or nurse practitioner or physician's assistant of a diagnosis 
of chronic obstructive pulmonary disease (COPD), asthma, or chronic lung disease. There is no evidence of a 
diagnosis of morbid obesity due to excess calories or risk for malnutrition, as the nutritionist's note on May 6, 
2022 reports a body-mass-index (BMI) in a healthy range.  
 
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 skilled nursing facility (SNF) services rendered from May 1, 2022, to May 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered on October 24, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the information now received does not support that the criterion were 
met for inpatient hospitalization. 
 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 that the review has determined that the did not record show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier ED 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 not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services rendered on October 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 23, 2022, to 
February 21, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the NOA. 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 January 23, 2022. The NOA was not received by the Plan until March 4, 
2022. 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 home health services provided 
from January 23, 2022, to February 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services billed with codes 74240, 74230, 
72040, 70100, 70310, and 71045 for February 9, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed with the correct place of service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11; however, 
the file shows that the services were performed in a mobile unit setting and should be billed with POS code 15. Therefore, we decided that the Plan does not have to pay for the mobile x-ray services billed with codes 74240, 
74230, 72040, 70100, 70310, and 71045 for February 9, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided from 
December 21, 2022, through January 27, 2023. 
 
You asked the Plan to pay for the services. You say that the services should be covered because you spoke with 
your primary care provider (PCP) and the confirmed that a referral was sent over. The Plan denied your 
request. The Plan says there is no documentation of a continued referral to the non-contracting provider nor is 
there any indication that failure to authorize the out-of-network coverage would likely lead to significant harm. 
The Plan states there are in-network providers available that can meet your behavioral health needs located in 
Plymouth. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider at issue in this case is not a network provider with the Plan. We looked at the file and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met.  
 
Documentation was not provided to show that you were referred to this provider by your PCP. 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 pay for the services. Therefore, we decided that the Plan does not have to pay for 
the outpatient mental health services provided from December 21, 2022, through January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 10, 2023. 
 
You asked the Plan to pay for the genetic testing billed. 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 
February 10, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on September 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the diagnosis code 
submitted for this service is inappropriate for the patient's age. 
 
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 diagnosis code submitted for this service is 
inappropriate for the patient's age. However, the Plan has not provided documentation supporting why the 
billed diagnosis code, O89.4, is inappropriate in this case. Without supporting documentation, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided on September 
22, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral repair of blepharoptosis. 
 
You asked the Plan to pre-approve a bilateral repair of blepharoptosis. You say that this surgery is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the medical criteria for this surgery 
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 a bilateral repair of blepharoptosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Goldmann visual fields do not demonstrate a greater than 12 degree or 
30% improvement with taping. 
 
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 bilateral repair of blepharoptosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bilateral repair of blepharoptosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 25, 2022, to 
December 31, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this provider is not participating with the Plan and is not a 
Medicare-certified provider. 
 
The Plan must follow Medicare rules. Medicare rules state that no provider or supplier shall receive payment 
for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that this provider is not a Medicare-certified provider. 
Therefore, we decided that the Plan does not have to pay for home health services provided from  
November 25, 2022, to December 31, 2022.