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 member's current condition requires additional 
SNF services. The Plan denied your request. The Plan says the continued admission in a SNF does 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 have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 
setting. Required services can be provided in the home, in an assisted living facility with home health care, or 
in a long-term care facility on a part time 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 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 laboratory services related to end-stage renal disease 
(ESRD) provided on November 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the lab tests should not be included in the 
dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryotherapy of occipital nerves (64640). 
 
You asked the Plan to pre-approve cryotherapy. You say that the enrollee is a good candidate for the 
cryotherapy of this same nerve, and you hope this will bring the enrollee more long-term relief. The Plan 
denied your request. The Plan says there is no medical necessity for cryotherapy of the occipital nerves. 
 
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 cryotherapy. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Official Disability Guidelines states that occipital nerve blocks are not recommended for 
treatment of occipital neuralgia and cervicogenic headaches, with or without corticosteroid. There has been 
little evidence that greater occipital nerve block (GONB) alone provides any sustained relief, since it seems to work best with concomitant therapy. Successful outcomes have been limited to small, non-controlled case 
series. Although short-term improvement has been noted in 50-90% of patients, many studies only reported 
immediate post-injection results. The literature has concluded that cryotherapy provided very limited benefit in 
the management of cervicogenic headaches and there is no high-quality randomized controlled trials (RCTs) 
and/or strong non-RCTs to support the use of this technique, despite numerous case reports that had 
demonstrated benefit. According to coverage guidelines, cryotherapy for the treatment of occipital neuralgia 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 cryotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cryotherapy of occipital nerves (64640).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 23, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on May 23, 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 member's current physical and medical condition 
requires an IRF admission. The Plan denied your request. The Plan says the member does not meet the 
Medicare criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this due to 
worsening heart failure. The Plan denied your request. The Plan says this procedure is 
experimental/investigational. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining the long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service October 12, 
2022. 
 You asked the Plan to pay for procedure code 11721. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for code 11721 is bundled into payment 
for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service October 12, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on November 
27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on November 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 12, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this claim should be reprocessed for 
payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 2, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Neuropsychological testing evaluation (96133). 
 
You asked the Plan to pre-approve the Neuropsychological testing evaluation. You say that the service is 
medically necessary. The Plan denied your request. The Plan says there is no explanation as to why additional 
2 hours is required and is therefore not considered reasonable or 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 the Neuropsychological testing 
evaluation. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no explanation as to why additional 2 hours is 
required and the neuropsychological testing exceeds the amount of time required for the testing. 
 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 Neuropsychological testing evaluation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Neuropsychological testing evaluation (96133).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the hammertoe correction surgery (28285). 
 
You asked the Plan to pre-approve the hammertoe correction surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 hammertoe correction surgery. Our 
reviewer says that the requested service is considered medically reasonable and necessary in this case. Our 
physician reviewer found physical examination reveals that this patient is suffering with rigidly contracted 
hammertoes left side causing pain. Physical findings include rigidly contracted digits, callous buildup, and skin 
irritation. It appears that correction of the hammertoes 2  4 left side meets the above-mentioned guidelines and 
can be 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 the hammertoe correction surgery have been met. Therefore, we decided that 
the Plan has to pre-approve the hammertoe correction surgery (28285).  
 
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 repeat bilateral medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve repeat MBBs. You say that the enrollee received facet injections previously 
with 80% anesthetic benefit but only moderate sustained benefit. You say the enrollee was approved in 
February for medial branch blocks which provided 80% pain relief for the day. You also say a second 
confirmatory block was ordered to see if radiofrequency ablation (RFA) would be of benefit. The Plan denied 
your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients who meet certain criteria. 
 
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 MBBs. Our reviewer says that 
repeat MBBs are not medically necessary. Our physician reviewer found the provided documentation indicates 
the enrollee has radiculopathy. The guidelines require the enrollee not have radiculopathy. Therefore, the 
reviewer found that the request for repeat MBBs 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 repeat MBBs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat bilateral medial branch blocks (MBBs).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a variable height hospital bed. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a variable height hospital bed is covered when 
specific criteria 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records show that you have a history of 
weakness, limited mobility, and a pressure ulcer. You are not able to move around on your own (non-
ambulatory) and are confined to a bed. You cannot perform transfers or pressure relief on your own. You have 
skin breakdown on the buttocks. You require positioning of the body that cannot be accomplished with an 
ordinary bed given your weakness and inability to perform pressure relief. You also have a history of chronic 
respiratory failure and congestive heart failure which would require elevation of the head of the bed greater 
than 30 degrees. The hospital bed is therefore reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a variable height hospital bed.  
 
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 the services (31575, 99214) provided on November 29, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (31575, 99214) is included in the 
global surgery payment for the procedure (15733) provided on September 26, 2022, which has a 90-day global 
period. 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 (31575, 99214) provided on 
November 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the nail trimming. 
 
You asked the Plan to pre-approve the nail trimming. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 nail trimming. Our reviewer says 
that the requested service is considered medically reasonable and necessary in this case. Our physician 
reviewer found this patient is indeed suffering with painful thickened mycotic toenails requiring debridement. 
 
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 nail trimming have been met. Therefore, we decided that the Plan has to pre-
approve the nail trimming.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. Wherever such a combination exists, there is a use additional code note at the 
etiology code, and a code first note at the manifestation code.  
 
We looked at the file and Medicare rules. The record shows that the claim was billed with only one diagnosis code, M40.13. This code has a code first note, which means it is a manifestation code and must be sequenced 
after an etiology code.  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 provided on 
November 22, 2022.