Persius/hicric huggingface dataset:
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF 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 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. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 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 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 an office visit (99214) provided on March 20, 2023.  
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the code billed. 
 
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 99214 is an office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making or must reach 30-39 minutes of total time. 
 
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 office visit. Our reviewer says that the records do not 
support the billed service. Our reviewer found the records show an appropriate exam, but not an appropriate history, or medical decision making of moderate level complexity. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (99214) provided on March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that this procedure would help the enrollee with 
their back pain. The Plan denied your request. The Plan says there are not enough studies on Vertiflex Superion 
to show it is safe and effective. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental, and more research 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code U0005. We decided that the Plan does not have to pay 
for procedure codes 87798, 87486, 87581, 87634, 87498, 87502, 87503, and 87801.  
 
You asked the Plan to pay for the lab testing services provided on April 3, 2023. You say that the results 
provide proper treatment. The Plan says that the codes cannot be separately reimbursed. 
 
We decided that the Plan has to pay for procedure code U0005.  
 
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 CPT Code Manual definition of code U0005 is infectious agent detection by nucleic acid (DNA or RNA); 
severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe 
technique, CDC or non-CDC, making use of high throughput technologies, completed within 2 calendar days 
from date of specimen collection (list separately in addition to either code U0003 or U0004). 
 
The file shows that the enrollee received Covid-19 testing. We have confirmed that code U0005 is an add-on 
code that has been billed with an appropriate primary procedure code, U0003. Based on this information, we 
decided that the Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for 
procedure code U0005 billed for date of service April 3, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 87798, 87486, 87581, 87634, 
87498, 87502, 87503, and 87801. 
 
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 file shows that a respiratory pathogen panel was provided. We find that the panel testing was not billed 
with a single code as required. Based on this information, we decided that the Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87798, 87486, 
87581, 87634, 87498, 87502, 87503, and 87801 billed for date of service April 3, 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 procedure code 88108-26 billed for date of service April 29, 
2023. 
 
You asked the Plan to pay for procedure code 88108-26. You say that that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 88108-26 is bundled into 
payment for code 88189. 
 
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, we have confirmed that code 
88108-26 is a column II code to column I code 88189. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88108-26 billed for date of service 
April 29, 2023.
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 admission to an IRF is medically necessary. 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 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. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 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 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 the enrollee requires continuous 
aggressive medical treatment as well as physical therapy until they regain their strength. The Plan denied your 
request. The Plan says admission to an LTACH is 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 there are no services at the LTACH that the enrollee cannot receive in their 
current 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 the enrollee meets LTACH admission 
criteria. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says admission to an LTACH is 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 no therapeutic advantage is offered with LTACH placement. 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested treatment does not meet the necessary criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Orthovisc. Our reviewer says that the 
requested drug does not meet the criteria for approval. Our physician reviewer found the requested use of 
Orthovisc is not FDA-approved for the enrollees diagnosis. The requested use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided by an OON provider on 
January 17, 2022, to January 25, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care by an OON provider. You say that the inpatient stay 
was medically necessary for the enrollee. The Plan denied your request. The Plan says that the services were 
provided out-of-network and were not approved in advanced. 
 
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. 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. 
 
  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 by an OON 
provider. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in 
this case. Our physician reviewer found that the enrollee was evaluated by an OON provider with dehydration, 
hyperglycemia, hypokalemia and possible urosepsis on January 17, 2022. The enrollee was treated with 
intravenous line (IV) fluids, IV antibiotics, electrolyte replacement and sliding scale insulin. Abdominal/pelvic 
computed tomography (CT) scan demonstrated possible colitis and they were diagnosed with new onset 
diabetes. The enrollees condition stabilized and improved with medical therapy and was discharged to home 
when considered medically stable on January 25, 2022. The review determined that the record showed that at 
the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 
care (including earlier emergency department (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 by an OON provider has been met. Therefore, we 
decided that the Plan has to pay for the acute inpatient hospital care provided by an OON provider on January 
17, 2022, to January 25, 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: 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 meets the full criteria for an IRF 
admission. 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 does 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80053, 80061, 82306, 82607, 82746, 
83036, 84443, 85025 and P9603) billed for date of service May 9, 2023. 
 You asked the Plan to pay for laboratory services. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says the order provided is insufficient to 
support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, there are no medical records or physician notes included with the order to support that these 
services were medically necessary and clearly intended by the enrollee's treating physician. In addition, there is 
no documentation to support that related travel services were provided. Therefore, we decided that the Plan 
does not have to pay for laboratory services (80053, 80061, 82306, 82607, 82746, 83036, 84443, 85025 and 
P9603) billed for date of service May 9, 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 you are requesting an expedited appeal 
of the LTACH denial. The Plan denied your request. The Plan says the LTACH services requested do not meet 
the requirements for approval. 
 
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 appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended. 
 
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: 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 inpatient rehabilitation was recommended by your 
medical team and without it, you won't get the proper rehabilitation if you're home by yourself. 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement; however, the 
documentation doesnt support that you meet criteria for admission to an acute inpatient rehabilitation facility. 
You can receive further services at a lower 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.