Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on January 25, 2023, billed 
with evaluation and management (EM) code 99233. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
code. 
 
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 99223 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 Practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the Date of service cannot be verified 
in the medical record provided.  
 
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 Practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Practitioner services provided on January 25, 2023, billed with evaluation and 
management (EM) code 99233.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care received November 10, 
2022, through December 9, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the enrollee's 100-day SNF benefit was exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 2, 2022, 
through November 9, 2022. The Plan has covered 100 days of SNF care.  
 
 
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) care received November 10, 2022, through 
December 9, 2022.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 is currently stable to 
discharge to an LTACH level of care. You say any lower level of care would likely result in recurrent 
hospitalization, morbidity, and potential mortality. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for admission to an LTACH.  
 
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 is no documentation provided indicating the medical necessity for 
admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital.  The enrollee does not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving care. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural neurostimulator. 
 You asked the Plan to pre-approve an epidural neurostimulator. You say that the enrollee has never had 
ablations and would not be considered a surgery consult due to their diabetic polyneuropathy. The Plan denied 
your request. The Plan says an epidural neurostimulator is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural neurostimulator. Our 
reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found that there is 
no documentation showing that the enrollee has undergone careful screening, evaluation, and diagnosis by a 
multidisciplinary team prior to implantation. However, the documentation does shows treatment by pain 
management with medications and treatment with physical therapy, but it does not include a psychological 
evaluation as required by the NCD. Therefore, the epidural neurostimulator is not medically reasonable and 
necessary for the enrollee. 
 
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 epidural neurostimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural neurostimulator.
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. You say daily therapy will enable the enrollee to make the functional improvements required 
for their safe return to home and community activities. The Plan denied your request. The Plan says the SNF 
request does not meet medical necessity criteria.  
 
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 have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist; 
however, the enrollee does not require skilled therapy services on a daily basis. 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: 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 has been hospitalized for heart failure 
and a UTI and needs the rehab to regain strength. 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (0345U) provided on 
February 13, 2023.  
 
You asked the Plan to pay for the GeneSight Psychotropic test. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says GeneSight Psychotropic has not been shown to be 
useful, is not considered medically necessary and appropriate, is not covered by Medicare and cannot be 
approved.  
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is covered when the 
criteria in the Medicare Rules section of this letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the GeneSight Psychotropic test. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that based on review 
the records provided there is documentation of this enrollee having tried at least one medication 
(citalopram/buspirone) which is noted although there is no documentation of the enrollee responding or not 
responding to the medications. The Medicare LCD requires the enrollee to be tried on at least one medication. 
The ordering psychiatrist must be board certified in psychiatry or neuropsychiatry. The ordering physician for 
this test is not a psychiatrist and is not boarded in psychiatry or neuropsychiatry. Documentation does not show 
the severity of the enrollees depressive illness and there is no documentation as to this enrollee having issues 
with sleep presently. Utilizing the information from Medicare LCD, this enrollee does not meet the criteria for 
GeneSight Psychotropic Assay. 
 
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 GeneSight Psychotropic test have not been met. Therefore, we decided that 
the Plan does not have to pay for the GeneSight Psychotropic test (0345U) provided on February 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) (99183) and 
hyperbaric oxygen under pressure (G0277). 
 
You asked the Plan to pre-approve HBOT and hyperbaric oxygen under pressure. You say that your team of 
doctors have advised that you should do radiation treatment to treat your disease. You also say that you have 
done a lot of research on HBOT and feel it is and would be a great benefit towards your healing and recovery. 
The Plan denied your request. The Plan says the NCD criteria do not appear to be met for a covered condition. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to the conditions 
listed in the Medicare rules section of this letter. 
 
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 HBOT and hyperbaric oxygen under 
pressure. Our reviewer says that the service is not reasonable or medically necessary.  Our physician reviewer 
found hyperbaric oxygen therapy (HBOT) is not a standard of care for the adjuvant treatment of breast cancer 
after lumpectomy. Our reviewer also found that the use is not supported by the National Comprehensive 
Cancer Network (NCCN) guidelines or the medical literature for this indication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT and hyperbaric oxygen under pressure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) (99183) and hyperbaric 
oxygen under pressure (G0277).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for 
admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the documentation supports that the complexity of the enrollees nursing, medical, and rehabilitation 
needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation supports that the enrollee requires treatment by multiple therapies, including physical therapy 
and occupational therapy, and an intensive rehabilitation therapy program. There is documentation that the 
enrollee is expected to 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 been met. Therefore, we decided that the Plan has to pre-approve 
an IRF admission and services.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and psychotherapy to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit and psychotherapy. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this is available in-network. 
 
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 
an office visit and psychotherapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5214), bone replacement 
grafts (D4263 x2), and alveoloplasty (D7231 x2). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says your benefit for the upper partial denture has already been exhausted. Bone 
replacement grafts and alveoloplasty are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
   
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the upper partial denture was exhausted on date of service June 27, 2023. Additionally, 
bone replacement grafts and alveoloplasty are not covered benefits. Therefore, we decided that the Plan does 
not have to pre-approve an upper partial denture (D5214), bone replacement grafts (D4263 x2), and 
alveoloplasty (D7231 x2).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found that the enrollee has not tried one of the 
preferred viscosupplemental treatments such as, Durolane, Monovisc, or Synvisc-One. Also, the documentation 
does not outline contraindications or that the Plan's required drugs would likely be less effective or likely have 
an adverse effect for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
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 the enrollee meets criteria for LTACH 
admission. 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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The health plan has approved ongoing 
care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
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.