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 you would like to be admitted to an IRF. You also 
say that you were independent before being hospitalized and want to return to being independent. The Plan 
denied your request. The Plan says you do not meet the criteria for IRF services.  
 
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 your nursing, medical, and rehabilitation needs are complex. However, you do 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for discography, each level; 
lumbar (62290). 
 
You asked the Plan to pre-approve an injection procedure. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the requested injections. 
 
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 an injection procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has magnetic resonance imaging (MRI) evidence of lumbar compression 
fractures and spinal stenosis. There is no documentation of any consideration for surgical intervention. The 
review has determined that the items/services at issue in this case are 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 an injection procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an injection procedure for discography, each level; lumbar (62290).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cataract surgery provided on June 19, 
2023. 
 
You asked the Plan to reduce the copayment for the cataract surgery. You say that you were unaware of the 
large copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $250 copayment for the cataract surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for the cataract surgery provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service June 23, 
2023. 
 You asked the Plan to pay for procedure code 74018. The Plan denied your request. The Plan says payment for 
code 74018 is bundled into payment for code 74420. 
 
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 74018 
is a column II code to column I code 74420. 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 74018 billed for date of service June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 17, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the specific testing provided in this case. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 17, 2023.
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 would continue ventilation 
weaning along with receiving therapy and wound care. The Plan denied your request. The Plan says LTACH 
care is not medically reasonable and 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 there is no therapeutic advantage to transfer the enrollee to a LTACH, and he still has 
a number of acute needs that should be resolved before he might be eligible. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract removal surgery provided on May 11, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the cataract removal surgery. You say that the enrollee's previous surgery was 
covered. The Plan denied your request. The Plan says this service is not covered when received by an out-of-
network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network outpatient surgery is not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the cataract removal surgery provided on May 11, 
2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 23, 2022, billed 
with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
December 23, 2022, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, and 
87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 6, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
March 31, 2023. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. The Plan denied your request. The Plan says 
procedure codes 99100 and 99140 are considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
March 31, 2023.
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 services are medically necessary for you to 
receive therapy services to return to your baseline. The Plan denied your request. The Plan says your records do 
not show that you require daily skilled services that can be provided only on an inpatient basis in a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and 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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says these services can be provided to the enrollee in an alternate setting.  
 
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. The enrollee does not require treatment by multiple therapies. 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 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 procedure code 99233 billed for date of service January 8, 
2023.  
 
You asked the Plan to pay for procedure code 99233. The Plan denied your request. The Plan says payment for 
code 99233 is bundled into payment for code 99222. 
 
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 99233 is a column II code to column I code 99222 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99233 billed for date of service January 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you need additional 
transportation for upcoming appointments. The Plan denied your request. The Plan says you have exhausted 
your benefit limit for 2023. 
 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 48 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 (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99356) provided on September 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99356 is "Prolonged service in the inpatient or 
observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to 
code for inpatient or observation Evaluation and Management service)". 
 
We find that CPT code 99356 is not supported in the medical record. Specifically, the records provided do not 
indicate the total time spent face to face 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 services (99356) provided on September 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service June 19, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the billed codes. 
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 95861 is needle electromyography; 2 extremities with or 
without related paraspinal areas. We find that CPT code 95861 is not supported in the medical record. The 
records do not include a formal report. Nerve testing to assess the level of paralysis during anesthesia is not 
separately reportable. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 95861 
billed for date of service June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions-lumbar spine thermal 
radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve lumbar spine thermal RFA. You say that lumbar spine thermal RFA is 
medically necessary. You say radiofrequency neurotomy is the best next step in the treatment of his lower back 
pain. The Plan denied your request. The Plan says the requested facet joint interventions-lumbar spine RFA 
does not meet the Medicare coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that a lumbar spine thermal RFA is covered when the 
criteria listed in the Medicare rules section of this decision 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 pre-approve lumbar spine thermal RFA. Our 
reviewer says that the requested lumbar spine thermal RFA is not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, the previous radiofrequency ablations on 
April 19, 2021 documented only minimal relief and not the required minimum of consistent 50% improvement 
in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously 
painful movements and activities of daily living as compared to baseline measurement using the same scale. 
The review has determined that the requested lumbar facet joint intervention/RFAs do not meet the Medicare 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 lumbar spine thermal RFA have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint interventions-lumbar spine thermal RFA.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found there is a clear past medical history that supports risk factors for peri-operative 
complications. There is also documentation of previous complications with sedation. 
 
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 been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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.