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

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve the SNF care. You say that the SNF admission is medically necessary. The 
Plan denied your request. The Plan says you do not meet the criteria for the SNF admission. 
 
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 the skilled nursing facility (SNF) care.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current acute setting.  
 
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. 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. Given there are offered alternatives, LTACH 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on May 16, 2023. 
 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 criteria for CPT 99285 was not met. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 enrollee was reevaluated in 
the emergency department (ED) for ongoing back pain with radiculopathy. An appropriate history and physical 
were documented. The medical decision making was not of high complexity. As such, the billing of CPT 
99285 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 emergency room services (procedure code 99285) rendered on May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of intranasal lesion (30117 x 2) and the 
repair of collapsed nasal valve (30469) with RFA. 
 
You asked the Plan to pre-approve the surgical procedure and RFA. You say that this non-invasive treatment is 
as good or better than the functional rhinoplasty. The Plan denied your request. The Plan says the request 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 the surgical procedure and RFA. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the record indicates the enrollee has nasal congestion, in the setting of 
nasal obstruction from hypertrophy of inferior nasal turbinate and deviated nasal septum. There is insufficient 
literature to support the safety and efficacy of the requested service for the enrollee's specific conditions. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. 
 
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 surgical procedure and RFA have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the removal of intranasal lesion (30117 x 2) and the repair of collapsed 
nasal valve (30469) with RFA.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (64555). 
 
You asked the Plan to pre-approve a Nalu neurostimulation system. You say that you are requesting 
reconsideration stating this procedure is medically necessary for patient. Her condition is worsening, and she 
has failed other conservative treatments. The Plan denied your request. The Plan says a review of the current 
medical literature shows that the evidence is insufficient to determine that the Nalu neurostimulation system is 
standard medical treatment. 
 
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 Nalu neurostimulation system. 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 a diagnosis of occipital neuralgia. Provided medical 
records and review of the current peer-reviewed medical literature do not document that use of the Nalu 
neurostimulation system has been shown in controlled studies in a Centers for Medicare & Medicaid Services 
(CMS) approved journal to result in sustained long term health benefits in enrollees with occipital neuralgia. 
 
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 Nalu neurostimulation system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array; 
peripheral nerve (64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that enrollee is not happy about their 
appeal being denied. The Plan denied your request. The Plan says the radiofrequency ablation 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 the radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
both diagnostic medial branch blocks need to produce 80% or greater pain relief to be considered positive, 
which has not been achieved. Therefore, the request is not 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart failure management system. 
 
You asked the Plan to pre-approve heart failure management system. You say that the requested heart failure 
management system is medically necessary. The Plan denied your request. The Plan says the requested heart 
failure management system 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 heart failure management system. Our 
reviewer says that the requested heart failure management system is not considered medically reasonable and 
necessary. Our physician reviewer found this particular testing does not currently have sufficient high quality 
supportive evidence to recommend generally to patients like this one. Therefore, without sufficient evidence made for this request, the heart failure management system will be considered not medically necessary at this 
time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of heart failure management system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve heart failure management system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the cervical spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has severe neck pain and there may be a 
pinched nerve. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
neck pain and radiculopathy in the setting of multiple previous cervical spine procedures. The record provided 
does not document and red flag signs or symptoms, abnormal neurological examination findings, or the failure 
of a course of conservative therapy. The requested service is not medically necessary and reasonable for the 
diagnosis and treatment for the enrollee's clinical condition at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the cervical spine.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the radiofrequency ablation of the splanchnic nerve. 
 
You asked the Plan to pre-approve the radiofrequency ablation of the splanchnic nerve. You say that the 
enrollee has received these injections over the past five years with a success rate of over 75% which usually 
lasts about 3-4 months. The Plan denied your request. The Plan says that the radiofrequency ablation of the 
splanchnic nerve 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 radiofrequency ablation of the 
splanchnic nerve. Our reviewer says that the radiofrequency ablation of the splanchnic nerve is medically 
necessary. Our physician reviewer found that high dose morphine will increase biliary tract pressure which is 
not desirable in a patient with ongoing pancreatic pain. Also, a duration of 3-6 months is clearly reported in the 
literature. Therefore, the request is 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 radiofrequency ablation of the splanchnic nerve have been met. Therefore, 
we decided that the Plan has to pre-approve the radiofrequency ablation of the splanchnic nerve.  
 
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: 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 enrollee is unable to complete any activities of 
daily living. You say the enrollee is weak and needs to get rehabilitation before going back home. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in an inpatient 
rehabilitation facility.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided by Geisinger Medical 
Center on August 9, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery services. You say that the claim should not have been denied. 
You are asking the Plan to review medical records and process the claim for payment. The Plan denied your 
request. The Plan says the enrollee must use network providers to get medical care and services. 
 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient surgery services provided by Geisinger 
Medical Center on August 9, 2023, 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 Volara interpulmonary percussive ventilator (IPV) 
system. 
 
You asked the Plan to pre-approve a Volara IPV system. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that studies do not demonstrate any advantage of IPV 
over that achieved with good pulmonary care in the hospital environment and there are no studies in the home 
setting. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Volara IPV system have not been met. Specifically, IPV in the home setting is not covered. 
Therefore, we decided that the Plan does not have to pre-approve a Volara interpulmonary percussive ventilator 
(IPV) system.
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 enrollee will benefit from acute inpatient 
rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says 
an IRF admission is not medically necessary, but skilled therapies as an outpatient or at a skilled nursing 
facility may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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 and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the request is medically necessary. The Plan denied 
your request. The Plan says 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 Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met.  Our physician reviewer found the provided documentation 
did not clearly show that you have tried zoledronic acid treatment or that zoledronic acid would not be 
appropriate for some reason to meet the step therapy requirements. It is not clear that Prolia would be more or 
less effective or cause more adverse effects than the suggested zoledronic acid based on the provided 
documentation of the treating physician in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on September 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that M54.51 has an Excludes1 note in relation to M54.42. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the therapy services provided on September 18, 2023.