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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs skilled nursing rehabilitation 
level of care for strengthening and ongoing supervision for synopal episodes for hands on support until it is 
safe to be alone. The Plan denied your request. The Plan says admission was denied for skilled therapy because 
the enrollee has no documented skilled therapy needs and should remain in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat interlaminar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve repeat ESI. You say that the enrollee has ten out of ten pain. The Plan 
denied your request. The Plan says the enrollee has not had a three month or longer sustained improvement in 
pain. The Plan also says the requested ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee had at least 50% pain relief for three months after the initial ESI. Therefore, the reviewer found that the requested ESI 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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat interlaminar epidural steroid injection (ESI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 
minutes provided on September 16, 2022, billed with procedure code 99239. 
 
You asked the Plan to pay for the hospital discharge. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says current procedural terminology (CPT) code 99239 remains 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 99239 is Hospital discharge day management; more than 30 
minutes. 
 
 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 hospital discharge. Our physician says that the documentation does not 
support procedure code 99239.  Our reviewer found that the time spent providing services to the member is not noted in 
the documentation.  As such, there is no evidence that greater than 30 minutes was spent providing discharge day services 
to the member. The billing of CPT 99239 is not supported.  
 
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 hospital discharge have not been met. Therefore, we decided that the Plan does not have to pay 
for the hospital discharge day management; more than 30 minutes provided on September 16, 2022, billed with 
procedure code 99239.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that you believe that you need this power 
scooter. The Plan denied your request. The Plan says the Medicare criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says 
that the records do not demonstrate that the power scooter criteria have been met. Our physician reviewer found the member is a 78-year-old female with a past medical history including chronic back pain, frequent 
falls and neuropathy who is requesting a motorized scooter. The documentation does not indicate the member 
requires a motorized scooter to accomplish mobility related self-care tasks. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on January 23, 2023. 
 
You asked the Plan to pay for the opioid treatment services. You say that these services were covered and 
billed correctly. The Plan denied your request. The Plan says that opioid treatment services must be billed on a 
facility claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for opioid treatment 
services provided on January 23, 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 pre-approve an epidural steroid injection (ESI). 
 You asked the Plan to pre-approve an ESI. You say that the requested service should be approved. The Plan 
denied your request. The Plan says he requested ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain criteria have been 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 an ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found there is no documentation of an 
inability to tolerate non-invasive conservative care or medical documentation of failure to respond to four (4) 
weeks of noninvasive conservative care. Therefore, the reviewer found that the requested ESI 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 an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
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 disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are 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 you were admitted for weakness and are in a skilled nursing facility now. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. The documentation does not 
support that you 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. Therefore, you 
do not meet criteria for the requested services. 
 
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: 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. The Plan denied your request. The Plan says the enrollee does not 
require ongoing skilled nursing are to resume a home medication regimen. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulators (PNS) device 
(64555, L8680). 
 
You asked the Plan to pre-approve a Sprint PNS device. You say that the enrollee was approved for this 
procedure and had it done but by mistake pulled a lead out, so they have to replace the lead. The Plan denied 
your request. The Plan says the requested device is not a covered benefit by Medicare for the enrollee's 
condition. 
 
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 Sprint PNS device. 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 chronic left knee pain. On April 27, 2023, SPRINT PNS placement 
was performed for peripheral genicular nerve stimulation at 2 locations (left superior medial genicular nerve, 
left inferior medial genicular nerve). On May 9, 2023, the enrollee presents s/p SPRINT L knee and reported 
70% relief for 1 week of left knee pain following the Sprint procedure. Unfortunately, the lead pulled out on 
May 15, 2023. He has tried conservative treatment including Oxycodone, Duragesic Patch, Baclofen with 
partial relief, HEP, Injections. MRI of the left knee May 2021 showed chronic full-thickness ACL tear, 
moderate chronic PCL sprain, chronic degenerative medial meniscal tear status post partial meniscectomy. 
Unfortunately, this is considered an experimental/ investigational procedure and replacing the leads is not 
considered 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 a Sprint PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint peripheral nerve stimulators (PNS) device (64555, L8680).
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. The Plan denied your request. The Plan says the enrollee's records 
do not show that you need to be seen by a rehabilitation doctor at least three times a week for evaluation of 
functional and medical goals and progress. Services needed may be provided safely in a lower level of care. 
 
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. 
 
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 the urinary tract infection (UTI) panel provided on October 
27, 2022. 
 
You asked the Plan to pay for the UTI panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this panel was not billed in accordance with Medicare guidelines. 
 The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UTI panel have not been met. Specifically, the records show that this was a single panel which 
was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to pay for 
the urinary tract infection (UTI) panel provided on October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneDose Genetic Response Report and the Hereditary 
Genetic cardiac test panel coded as 81225, 81328, 81226, 81227, 81335, 81479, 81238, 81231, 81232, 81240, 
81241, 81291 and 81306 provided November 10, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the results have been added to the enrollee 
charts and shall be inclusive as part of the enrollee's on-going plan of treatment and future medication 
selections. The Plan denied your request. The Plan says the records do not support that the enrollee meets the 
criteria. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a history of hypertension, coronary artery disease, 
hyperlipidemia, cerebrovascular accident and snoring who underwent GeneDose Genetic Response Report and 
the Hereditary genetic cardiac test panel. There is no specific clinical rationale for the obtained laboratory tests. 
The review has determined that the medical records provided did not meet the requirements listed in the LCD 
for Medicare 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for GeneDose Genetic Response Report and the Hereditary Genetic cardiac test panel coded as 
81225, 81328, 81226, 81227, 81335, 81479, 81238, 81231, 81232, 81240, 81241, 81291 and 81306 provided 
November 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on January 9, 2023. 
 
You asked the Plan to pay for the opioid treatment services. You say that these services are covered and were 
billed correctly. The Plan denied your request. The Plan says that you must bill these services on a facility 
claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for opioid treatment 
services provided on January 9, 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 code 99223 billed for date of service March 25, 2022. 
 
You asked the Plan to pay for code 99223. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says the medical records do not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, we looked at the medical records for the evaluation and management service that occurred on March 25, 
2022.  According to these medical records, the nurse practitioner who performed the pain management 
consultation that you are billing for is not the same provider you have listed as the provider on the claim. The 
Plan attested that they tried to contact you on multiple occasions to fix the issue to no avail. Therefore, we 
decided that the Plan does not have to pay for code 99223 billed for date of service March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS system.  
You asked the Plan to pre-approve the SPRINT PNS system. You say that the SPRINT PNS system is 
necessary to alleviate your back pain. The Plan denied your request. The Plan says the SPRINT PNS system 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 SPRINT PNS system. Our 
reviewer says that the SPRINT PNS system is not considered medically necessary. Our physician reviewer 
found that the PNS device is experimental for back pain. 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 the SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS system.