Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency care provided on January 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this type of facility 
is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare is creating additional flexibilities to 
allow licensed independent freestanding emergency departments (EDs) to participate in Medicare and 
Medicaid to help address the urgent need to increase hospital capacity to provide care to patients.  
 
We looked at the file and Medicare rules. In this case, the services were provided during the COVID-19 
emergency period. As such, the freestanding emergency department is payable for the services provided. Based 
on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we 
decided that the Plan has to pay for the emergency care provided on January 7, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical 
necessity of an MRI without first trying conservative therapy has not been established in the records submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on February 15, 2023.  
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
ordered by the treating physician who makes the professional determination of diagnosis and medical necessity 
to successfully treat the enrollee The Plan denied your request. The Plan says ordering a multi-class panel of 
definitive urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
enrollee does not have an indication for definitive testing. There is no documentation of screening test results 
which are positive or inconsistent with prescription medications, dosing schedules, or history and expected 
results. The testing was 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 the definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on February 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 5, 2022, to 
March 10, 2022. 
 You asked the Plan to pay for the home health services. You say that no prior authorization is required for these 
services. 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 March 5, 2022. The NOA was not received by the Plan until May 5, 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 
March 5, 2022, to March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that the enrollee has severe facet degeneration and 
axial low back pain. The Plan denied your request. The Plan says that the paravertebral facet joint injections are 
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 injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that the firs medical branch 
block (MBB) on the right was prior to the enrollees cancer diagnosis and treatment. The right L4-L5-S1 MBB 
provided on 02/15/2022 provided 0% relief of pain. As the MBB treats the facet, and not where their metastatic 
lesions were occurring and if the facets were a pain generator it is reasonable to expect some sort of response 
even if the metastatic pain was more prominent. Therefore, the enrollee does not meet the LCD coverage 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve paravertebral facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 5, 2022, to 
July 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services that were provided were 
all medically necessary. The Plan denied your request. The Plan says a lower level of care would have been 
more appropriate. 
 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 the workup did not sufficiently support the enrollee with a complex or serious 
infection or other condition that would not effectively be able to be treated safely at a lower level of care. There 
was no indication the enrollee would require hospital services that would likely cross two midnights 
considering the provided documentation on the admission date.  
 
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 the acute inpatient hospital care provided July 5, 2022, to July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on November 18, 2022. 
 
You asked the Plan to pay for outpatient hospital care. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this claim is returned to 
the provider for correction due to I/OCE billing edit errors. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that edit 62 applies to an 
outpatient claim when a code which is not recognized by OPPS is reported. Services with a status indicator of 
B will always return edit 62. When edit 62 is invoked, the entire claim is returned to the provider for correction. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient hospital care have not been met. Specifically, this claim includes code 99202, which has 
a status indicator of B and therefore is not recognized by OPPS. This means that the entire claim is returned to 
the provider for correction before payment may be made. Please note that this claim may also contain 
additional errors on individual lines. Therefore, we decided that the Plan does not have to pay for outpatient 
hospital services provided on November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a polysomnography; age 6 years or older, sleep staging with 4 or 
more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel 
ventilation, attended by a technologist (95811). 
 
You asked the Plan to pre-approve a Titration Study. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the enrollee is not using the CPAP machine and does not meet criteria 
for the study. 
 The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Titration Study. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of severe obstructive sleep apnea confirmed on a sleep test dated 
June 27, 2023, with recommendations for a titration study. Based on the medical records provided and the rules 
in the Local Coverage Determination (LCD) Polysomnography L36593 there is documentation that the enrollee 
meets criteria for the requested testing per Medicare criteria. The LCD states "repeat PSG (polysomnography) 
or HST (home sleep testing) for diagnosing sleep apnea requires documentation justifying the medical 
necessity for the repeated test. Repeat PSG may be indicated if initiation of therapy or confirmation of the 
efficacy of prescribed therapy is needed." Provided medical records document initiation of therapy is needed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Titration Study have been met. Therefore, we decided that the Plan has to pre-
approve a polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, 
with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist 
(95811).  
 
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 posterior lumbar microdiscectomy at L5-S1 (63030). 
 
You asked the Plan to pre-approve a microdiscectomy. You say that the requested procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the documentation does not support the 
surgical necessity for the area of the proposed surgery. 
 
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 microdiscectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate severe root compression. The reviewer 
also found there is no correlation between the provided imaging and exam. Therefore, the reviewer found that 
the requested posterior lumbar microdiscectomy at L5 to S1 is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a microdiscectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a posterior lumbar microdiscectomy at L5-S1 (63030).
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 a lower level of any kind is not enough to adequately 
and quickly ensure that the enrollee is able to return home at the appropriate functional level that is required to 
return to the quality of life they were previously living. 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 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 5, 2023. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the performance of a total thoracoscopic MAZE 
procedure with left atrial appendage exclusion (33266), and an inpatient admission. 
 
You asked the Plan to pre-approve a total thoracoscopic MAZE procedure. You say that this procedure is 
medically necessary for the enrollee. 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 a total thoracoscopic MAZE procedure. 
Our reviewer says that the requested performance of a total thoracoscopic MAZE procedure is not considered 
medically reasonable and necessary in this case. Our physician reviewer found supportive, randomized, longer-
term clinical studies are awaited, including direct comparisons of such ablation procedures with alternative treatment options. Therefore, the reviewer found that the performance of a convergent hybrid ablation 
procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a total thoracoscopic MAZE procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the performance of a total thoracoscopic MAZE procedure 
with left atrial appendage exclusion (33266), and an inpatient admission.
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 reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require intensive rehabilitation to get back to 
living independently prior to the fall and breaking your hip. The Plan denied your request. The Plan says you 
do not meet the Medicare criteria 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 that your 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Kit.  
You asked the Plan to pre-approve a Freestyle Libre 2 Kit. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 Kit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 2 Kit.