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 you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the request for admission to a SNF is denied as 
not medically necessary.  
 
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. The enrollees care needs can be provided 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 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 a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that you have had two procedures done which 
have not worked. You say that you have serious problems, can barely move, and are in serious pain. You say 
that the medication you have to take makes you feel drunk. You say that the Vertiflex device will allow you to 
move freely, without pain.  The Plan denied your request. The Plan says the Vertiflex device is unproven and 
not medically necessary due to insufficient evidence of efficacy.  
 
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 a Vertiflex device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is considered 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: 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 your health is declining every day and you do not 
have assistance living at home. The Plan denied your request. The Plan says the SNF services you are 
requesting do not meet the requirements for approval. 
 
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 not 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/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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tenodesis of long tendon of biceps rendered on October 21, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be reprocessed for payment following 
Medicare guidelines. The Plan denied your request. The Plan says the records do not support the services 
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 23430 is "Tenodesis of long tendon of biceps." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 23430-59 is not 
supported as separately identifiable procedure. The record states that the biceps tenodesis was performed as 
part of the glenohumeral joint arthroplasty; this is included in the code for the main procedure and cannot be 
reported separately. Modifier 59 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for tenodesis of long tendon of biceps rendered on October 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will require a coordination of multiple 
disciplines under the direction of the rehabilitation physician to attain maximal level of progression prior to 
discharge. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support the necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee may 
have a need for physical therapy and/or occupational therapy, the enrollee's rehabilitation needs can be 
provided in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve telephone evaluation and management service (99441) 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve telephone evaluation and management service to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
telephone evaluation and management service (99441) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transperineal placement of biodegradable material 
(SpaceOAR hydrogel spacer) (55874). 
 
You asked the Plan to pre-approve the SpaceOAR. You say that to allow the provider to safely decrease 
treatment length from 44 fractions of image guided radiation therapy (IGRT)/intensity modulated radiation 
therapy (IMRT) down to 27 fractions, it is the provider's standard practice to have SpaceOAR prior to 
radiotherapy. You also say that the provider feels the requested treatment is appropriate and medically 
necessary for the enrollee.  The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that polyethylene-glycol (PEG) hydrogel is covered once 
in patients with clinically localized prostate cancer with low or favorable intermediate prostate cancer risk 
group. 
 
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 SpaceOAR. Our reviewer says that 
the requested SpaceOAR is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate the enrollee has low or favorable intermediate risk or clinical stage T1-T2 
prostate cancer as required for coverage of polyethylene-glycol (PEG) hydrogel. Therefore, the reviewer found 
that the requested procedure is not medically 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 SpaceOAR have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transperineal placement of biodegradable material (SpaceOAR hydrogel spacer) (55874).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the provided documentation is insufficient to support that a home ventilator is medically reasonable and 
necessary for the enrollee in this case. Products classified as HCPCS code E0466, when used to provide 
continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) (with or without 
backup rate) therapy, regardless of the underlying medical condition, shall not be paid. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic facet joint injections (64493). 
 
You asked the Plan to pre-approve therapeutic facet joint injections. You say that therapeutic facet joint 
injections are a medical necessity for the enrollee. The Plan denied your request. The Plan says therapeutic 
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 therapeutic facet joint injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that it does not appear that the enrollee has received medial branch blocks, and 
on a visit from June 13, 2023, it was clarified that therapeutic facet joint injections were being requested. 
Diagnostic facet joint procedures such as medial branch blocks are a prerequisite for the requested services that 
has not been fulfilled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic facet joint injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve therapeutic facet joint injections (64493).
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 your life/health is in danger it is 
imperative for long term acute care admission. The Plan denied your request. The Plan says it is not safe for 
you to leave the hospital currently because documentation shows you have ongoing need for high flow oxygen 
and electrolyte abnormalities. 
 
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 are no services available at the LTACH that you require that are not available at 
the current health care setting being offered by the health plan.  
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your mom can only take 10 steps and the nurses and 
doctors think she needs to go to rehabilitation. You also say this is the best place for her to be as she needs help 
to get her strength back so she can walk.  The Plan denied your request. The Plan says based on Medicare 
guidelines, 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 at the current functional level, the enrollee is unlikely to make a significant functional 
recovery and does not need specialized and intensive therapies consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach in an IRF. The complexity of the enrollee's nursing, 
rehabilitation, and medical, needs (combined complexity) does not require an acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. The enrollee needs routine physical 
therapy and occupational therapy. The document does not support necessity for admission to an IRF. While the 
enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be 
provided in an alternate setting such as in a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac monitoring (93226) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve cardiac monitoring to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cardiac monitoring (93226) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective outer surface covering system for 
the hip (L5966) and a flexible keel foot (L5972). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes state the enrollee is a K1 ambulator. 
 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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the flexible keel foot (L5972) exceeds the enrollee's functional needs and is not medically necessary. 
The treating medical physician provider documentation does not support that the enrollee has progressed to a 
K2 ambulator or will be participating in activities that are a K2 level. L5966 is not medically necessary, as the 
documentation does not support that the enrollee has special needs for protection against unusually harsh 
environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of 
protection that is afforded by a standard prosthetic cover.  
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a flexible protective outer surface covering system for the hip (L5966) and a flexible keel foot 
(L5972).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95908, 95927, 95937, 95955 rendered on 
February 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 95908: 
 
Nerve conduction studies; 3-4 studies  
CPT 95927: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in the trunk or head 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records.  
 
Our reviewer found that the records do not support CPT 95908, as no nerve conduction studies (NCS) were 
performed during the surgery. There was pedicle screw testing performed; however, that is considered part of 
the electromyography (EMG) services provided. This is distinct from a NCS, and the records do not support 
NCS having been done. 
 
In terms of CPT 95927, the records do not support this, as the somatosensory evoked potentials (SSEPs) 
performed were otherwise reflected in the more appropriate code - CPT 93938. 
 
In terms of CPT 95955, the records do not support this as the limited electroencephalogram (EEG) recorded 
(two channels) is below the minimum number of channels to be recorded per American Clinical 
Neurophysiology Society (ACNS) guidelines. As the minimum technical standards were not satisfied, the code 
cannot be supported.  
 
In terms of CPT 95937, this testing was not done for neuromuscular junction testing. Rather, it was done to test 
anesthesia. This would be considered part of the EMG services, according to coding guidelines. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95908, 95927, 95937, 95955 rendered on February 10, 2021.