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

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
abdominal aorta and bilateral iliofemoral lower extremity runoff. 
 
You asked the Plan to pre-approve the CTA. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CTA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a handwritten sheet showing velocities of 
lower extremity arteries was done on December 29, 2022, but no formal impression or notes are included.  
Peripheral pulses are normal throughout and there is no ankle-brachial index (ABI) in the chart to support the 
notion of peripheral vascular compromise. The medical necessity of the requested CTA of the aorta and runoff 
has not been established in the records provided. 
 
 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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomographic angiography (CTA) of the abdominal aorta and bilateral iliofemoral 
lower extremity runoff.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of acute rehabilitation services for the enrollee. The Plan denied your request. The Plan says the enrollee does 
not meet the guidelines for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that because of the enrollee's complex 
medical needs, the best course of treatment is admission to an LTACH setting where they can be closely 
monitored by a team of physicians daily. You would like reconsideration based on the records submitted. The 
Plan denied your request. The Plan says admission to an LTACH is being denied as not medically necessary. 
 
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 all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 5, 2023, to 
February 3, 2023.  
 
You asked the Plan to pay for home health services. You say that the home health services were 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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee does 
not have documented home health skilled nursing needs. The enrollee does not have documented home health 
physical therapy needs. There are no records for the dates of services in question.  As such, there is no evidence 
that the billed services were medically necessary, reasonable, or provided. 
 
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 pay for the home health services provided from January 5, 2023, to February 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our doctor found that the 
PET scan is not medically necessary. Our reviewer says that the enrollee is only noted to have a cognitive 
impairment. There was no mention in the notes of either AD or FTD. The base requirement for this study is not 
met. Therefore, this would not meet Medicare criteria for coverage.  
 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug code J3490 provided on November 1, 2022. 
 
You asked the Plan to pay for J3490. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says there is a more appropriate code to use of J1170. 
 
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 J3490 is unclassified drug. 
 
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 J3490. Our reviewer says that this code does not meet criteria 
for payment. Our reviewer found documentation supports that hydromorphone was provided. There is an 
assigned code for the drug give. Therefore, J3490 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of J3490 have not been met. Therefore, we decided that the Plan does not have to 
pay for drug code J3490 provided on November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the enrollee has an acute compression fracture 
caused by osteoporosis and other causes of pain have been ruled out by imaging. You say that the enrollee has 
maximized non-surgical treatments and the kyphoplasty to repair the fracture should be approved. The Plan 
denied your request. The Plan says medical necessity criteria has 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 kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of a fracture brace and more conservative measures are 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 a kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TENS therapy. 
 You asked the Plan to pre-approve TENS therapy. You say that the requested therapy is a necessity for your 
care. The Plan denied your request. The Plan says rules for coverage for TENS therapy have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of TENS for CLBP is covered when the 
enrollee is enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of TENS therapy have not been met. Specifically, the case record does not support that you are 
enrolled in an approved clinical study. Therefore, we decided that the Plan does not have to pre-approve TENS 
therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you need additional trips to get to your 
dialysis appointments. The Plan denied your request. The Plan says your 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 72 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 trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable X-ray services provided on February 9, 2023. 
 
You asked the Plan to pay for portable X-ray services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if the mobile unit is serving an entity for which 
another POS code already exists, providers should use the POS code for that entity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable X-ray services have not been met. Specifically, the claim was reported with POS 11, indicating an office setting. The case record does not support that the services at issue were provided in an 
office setting. Therefore, we decided that the Plan does not have to pay for portable X-ray services provided on 
February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on January 12, 2023.  
 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 the inpatient codes are incorrectly billed on an 
outpatient claim. 
 
The Plan must follow Medicare rules. Medicare rules say that services for which payment under the outpatient 
prospective payment system (OPPS) is appropriate and the Secretary has determined that the services 
designated to be "inpatient only" services are not appropriate to be furnished in a hospital outpatient 
department. 
 
We looked at 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. The billed Procedure codes 33967 and 92941 
are inpatient procedure codes as per status indicator C and is incorrectly billed on an outpatient claim. All other 
billed procedure codes available on the claim are correctly denied as services billed on same day as inpatient 
procedure. Therefore, we decided that the Plan does not have to pay for Practitioner services provided on 
January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a suction assisted lipectomy; lower extremity (15879). 
 
You asked the Plan to pre-approve an outpatient surgery. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested procedure is designated as 
cosmetic. This procedure is requested to improve the appearance (cosmetic service) of the legs. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an outpatient surgery have not been met. Specifically, the requested surgery is considered cosmetic 
and will be denied as non-covered. Therefore, we decided that the Plan does not have to pre-approve a suction 
assisted lipectomy; lower extremity (15879).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 8, 2022, to 
January 6, 2023. 
 You asked the Plan to pay for the home health services. You say that you have provided the required 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 December 8, 2022. The NOA was not received by the Plan until April 17, 
2023. 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 December 8, 2022, to January 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 23, 2022, 
to March 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this is not a duplicate claim and 
it should be processed. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 23, 2022, to 
March 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 76942-26-59 billed for date of service January 18, 
2022. 
 
You asked the Plan to pay for code 76942-26-59. You say that the medical records support payment of this 
code. The Plan denied your request. The Plan says the use of the 59 modifier billed with code 76942-26-59 is 
not supported by the medical record. This code is included in 64447 and is not separately identifiable or 
distinct. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 76942-26-59 Our reviewer says that the 
use of the 59 modifier to allow for separate payment of code 76942-26-59 is not supported by the medical 
record. Our physician reviewer found per the American Society of Anesthesiologists "Somatic Nerve Injection codes 64415, 64416, 64417, 64445, 64446, 64447, and 64448 describe only injection of an anesthetic agent in 
the area of the peripheral nerve and/or catheter placement for postoperative pain management. Starting January 
1, 2023, somatic nerve injection codes will be bundled with imaging services".  The operative report does not 
include documentation to support a distinct procedural service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 76942-26-59 have not been met. Therefore, we decided that the Plan does 
not have to pay for code 76942-26-59 billed for date of service January 18, 2022.
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 is getting weaker every day that they are 
not in physical and occupational therapy. The Plan denied your request. The Plan says the 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 enrollee's medical conditions appear improved on stable medications with no 
issues that appear to require a physicians evaluation three or more times per week in a hospital setting. The 
enrollee does require physical therapy and occupational therapy services however, the medical records do not 
support that the intensive inpatient rehabilitation therapy program is necessary and that therapy at a lower level 
of care such as in a skilled nursing facility is not appropriate for the enrollee. Based on the medical records 
provided, there is concern that the enrollee will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility due to their reported level of 
weakness and poor endurance.  
 
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 you need the intensive rehab to regain strength and 
be able to live at home. The Plan denied your request. The Plan says the IRF services you are requesting 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 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 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 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 acute inpatient rehabilitation facility (IRF) admission and services.