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

 
We decided that the Plan does not have to pay for procedure code 0315U billed for date of service July 2, 2023. 
 
You asked the Plan to pay for the billed service. You say that the test is a covered benefit. The Plan denied 
your request. The Plan says the test is experimental.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the DecisionDx-SCC test, billed with CPT code 0315U, is not supported in the medical record. 
The records do not show that the provider managing the enrollees condition has demonstrated that the use of 
biomarkers will be used to assist in the management/treatment of the enrollee. Based on this information, we 
decided that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 0315U billed for date of service July 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's needs could be met in an alternate level 
of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable with no acuity and does not need a Physical Medicine 
and Rehabilitation (PMR) physicians supervision 3 times a week in an IRF. No acute rehabilitation skilled 
nursing needs are identified or documented. The enrollee needs routine physical therapy and occupational 
therapy and does not need specialized 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 documentation does not support the necessity for admission to an IRF. With no medical acuity, and no 
rehabilitation nursing needs as described above the enrollee does not require an IRF stay. The enrollees 
rehabilitaiton needs can be provided in an alternate and low intensity setting such as in a skilled nursing facility 
(SNF) or continued with services at home.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has medical needs that make 
LTACH admission the safest discharge plan. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and is currently unstable for transfer 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 the recent notes describe the enrollee as still with progressive renal failure 
requiring treatment and monitoring. The enrollee appears to still be unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to 
the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply codes A5120 and A6250 billed for dates of service 
May 24, 2023, to July 12, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not covered.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes A5120 and A6250 are not supported. Code A5120 was not billed with the AU 
modifier as required. Code A6250 does not meet the statutory definition of a dressing. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for supply codes A5120 and A6250 billed for dates of service 
May 24, 2023, to July 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc NP procedure (0627T). 
 
You asked the Plan to pre-approve a VIA Disc NP procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is unproven and 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 a VIA Disc NP procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy. 
 
   
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 VIA Disc NP procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a VIA Disc NP procedure (0627T).
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's medical and therapy needs could be 
met in a skilled nursing unit. The Plan denied your request. The Plan says admission to the IRF is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) does not require 
an acute hospital inpatient rehabiltation stay with an interdisciplinary approach to rehabilitative care. The 
enrollee's rehabilitation needs can be safely provided in a low intensity alternate setting such as continuing in -
home with services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service September 
10, 2023, to September 23, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the provider was authorized to provide 
services. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service September 10, 2023, to September 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of neurostimulator electrode array; 
sacral nerve (transforaminal placement) (64581). 
 You asked the Plan to pre-approve open implantation of neurostimulator electrode array; sacral nerve. You say 
that this is medically necessary. The Plan denied your request. The Plan says records do not show 
documentation of a 50% or greater improvement in incontinence symptoms measured through voiding diaries. 
The request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation can be 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 open implantation of neurostimulator 
electrode array; sacral nerve. Our reviewer says that the enrollee does not meet criteria for coverage. Our 
physician reviewer found the records in this case do not document a 50% or greater improvement in 
incontinence, urgency or frequency through test stimulation as measured through voiding diaries. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of open implantation of neurostimulator electrode array; sacral nerve have not 
been met. Therefore, we decided that the Plan does not have to pre-approve open implantation of 
neurostimulator electrode array; sacral nerve (transforaminal placement) (64581).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service June 7, 
2023, to June 28, 2023. 
 
You asked the Plan to pay for the billed services. You say that the system has the ability to accelerate post 
operative healing. The Plan denied your request. The Plan says the services are excluded from coverage. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code E0675 is not supported in the medical record. The PCD coded E0675 is used to treat 
peripheral arterial disease. The records show that the provided device was used to prevent deep vein thrombosis 
after surgery. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code E0675 billed 
for dates of service June 7, 2023, to June 28, 2023.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the records do not document that the enrollee currently has complex 
medical, nursing or rehabilitation needs that require 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 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 the enrollee 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued SNF care. 
 
You asked the Plan to pay for continued SNF care. You say that continued SNF care is medically necessary. 
The Plan denied your request. The Plan says it covers up to 100 skilled nursing facility days.  
 
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 118 days of SNF care during the benefit period from September 23, 
2023, through January 18, 2024. The Plan has covered 118 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 continued SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. You say that the enrollee meets all of the Medicare guidelines to 
have this drug. The Plan denied your request. The Plan says the Plan's preferred viscosupplementation products 
are Durolane, Euflexxa, Synvisc, or Synvisc-One. 
 
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 Gelsyn-3. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Gelsyn-3. Our physician reviewer found the 
enrollee has not tried and failed one of the Plan's preferred drugs of Durolane, Euflexxa, Synvisc, or Synvisc-
One. The record does not show that one of these drugs would likely be less effective and/or have adverse 
effects 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Gelsyn-3.
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 requires continued care from both 
occupational and physical therapy disciplines in order to maximize their potential for recovery and return to 
their independent prior level of functioning. 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 (SNF) 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 enrollee is medically stable and does not need a physicians supervision three 
times a week in an IRF. At the current functional level, the enrollee needs physical and occupational therapy. 
The enrollee does not need intensive therapies consisting of at least three hours of therapy per day at least five 
days per week with multidisciplinary approach in an IRF. Documentation does not support necessity for 
admission to an IRF. The complexity of the enrollees medical, rehabilitation, and nursing needs (combined 
complexity) does not require acute hospital inpatient rehabilitation stay with an interdisciplinary approach to 
rehabilitative care. The enrollees rehabilitation needs can be safely provided in a low intensity alternate setting 
such as continuing in an SNF.  
 
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 Cinvanti. 
 You asked the Plan to pre-approve Cinvanti. You say that the provider and enrollee both agree on the treatment 
plan. 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 Cinvanti. Our reviewer says that the 
criteria for coverage of Cinvanti have not been met.  Our physician reviewer found the Plan requires a trial of 
Emend before they will approve the requested drug. The provided records do not indicate that the enrollee has 
tried and failed the Plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. The elements 
of the coverage criteria are not satisfied and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cinvanti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cinvanti.
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 requires LTACH services 
for the best chance at recovery. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval of the requested LTACH services.  
 
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 enrollees medical problems remain unstable and transfer to an LTACH is unsafe 
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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an ILR. 
  You asked the Plan to pre-approve the requested ILR procedure. The Plan denied your request. The Plan says 
an implanted loop recorder is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an implanted monitor. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an ILR.