Persius/hicric huggingface dataset:
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 at times the enrollee is not able to walk so they 
would stay in bed until their spouse gets home.  You say that enrollee is unable to use the bathroom while their 
spouse is away. The Plan denied your request. The Plan says an IRF admission 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 that the enrollee has chronic weakness and requires minimal assist to function. The 
enrollee also does not require intensive or complex rehabilitation or frequent physician oversight. Therefore, 
the request is not medically or reasonably 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 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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denied 
services, stating that the enrollee was totally independent before being in the hospital. The enrollee was living 
alone and able to provide everything for themself. The goal is for the enrollee to return back home as close to 
their previous function as possible. The Plan denied your request. The Plan says the inpatient rehabilitation 
facility (IRF) services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual, the medical record 
overall significantly complies with the various documentation requirements for IRF admission (e.g., as best 
summarized by hospitalist note on October 8, 2023).  The enrollees condition is in fact complex and fragile, 
and there is every reason to expect that they will participate in and benefit from these 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies are 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 a sleep study. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you do not currently meet criteria for 
this facility-based sleep study. Documentation does not support that you have a complex sleep syndrome, other 
concurrent sleep disorders or an inconclusive result from a home sleep apnea test (HSAT). The recommended 
test (HSAT) has not been shown to be contraindicated in you. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
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 not receiving the physical therapy 
services needed for their rehabilitation. 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 is medically stable and improving toward their baseline. 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 does not require treatment by multiple 
therapies. 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.  
 
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 pay for inpatient hospital services provided on February 20, 2023, to 
February 23, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says diagnosis code J96.21 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.21. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that diagnosis code J96.21 is not supported. Our physician reviewer found the records do not support that the 
enrollee has respiratory failure. She had adequate oxygenation on her usual level of oxygen support and was 
not in distress. She had baseline chronic obstructive pulmonary disease (COPD) and only a minor increase in 
oxygen requirements during the acute phase of illness. The records do not support the billing of diagnosis code 
J96.21.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 20, 2023, to February 23, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does 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 is minimally response, has a percutaneous endoscopic gastrostomy 
(PEG) for nutritional support and receiving high flow oxygen via tracheostomy. There have been no weaning 
attempts. There is no documentation provided indicating medical necessity for admission to a LTACH. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is 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 health 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on December 28, 2022, 
to January 3, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says secondary diagnosis code J96.91 is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.91. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that secondary diagnosis code J96.91 is not supported. Our physician reviewer found the records do not support 
that the enrollee meets the criteria for respiratory failure. He did not require ventilatory support or high levels 
of oxygen support. He was not in distress and did not have elevated respiratory rate and was not hypoxic. The 
records do not support the billing of secondary diagnosis J96.91.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 28, 2022, to January 3, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of a peripheral nerve 
stimulator. 
 
You asked the Plan to pre-approve the nerve stimulator. You say that this procedure is necessary to address 
pain and restore function. 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 nerve stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this procedure is considered experimental/investigational. This therapy is the 
subject of ongoing clinical trials. Therefore, the request is deemed 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 nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous implantation of a peripheral nerve stimulator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance code A0427-QL billed for date of service 
November 24, 2022. 
 
You asked the Plan to pay for the billed service. You say that the ambulance was called to evaluate the 
enrollee. The Plan denied your request. The Plan says an incorrect code was billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A0427is not supported when billed with the -QL modifier. There is a more applicable 
code available to describe the services provided. 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 
ambulance code A0427-QL billed for date of service November 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of anesthetic or steroid into the genicular 
nerve (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the attached clinical notes provide 
medical evidence for approval of this procedure. 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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the procedure is considered experimental/investigational at this time. This 
procedure is the subject of ongoing clinical trials. The enrollee is not enrolled in a clinical trial. Therefore, the 
request is deemed 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of anesthetic or steroid into the genicular nerve (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95165 and 95144 billed for dates of service 
March 29, 2023, to April 5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the codes. The Plan 
denied your request. The Plan says the billed services cannot be verified. 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 95165 is professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses). We find that 10 units CPT code 95165 is not supported in the medical records. The record does not 
show that vials were prepped on this date of service at issue. 
 
The CPT Code Manual definition of code 95144 is professional services for the supervision of preparation and 
provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials). We find that 
30 units of CPT code 95144 is not supported in the medical record for each date of service at issue. The records 
provided do not show that 30 vials were used on each of the dates of service at issue. 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 codes 95165 and 95144 billed for dates of service 
March 29, 2023, to April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99307 billed for date of service April 21, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the service was not provided according to coverage guidelines. 
 
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 99307 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient. 
 
We find that CPT code 99307 is not supported. The records show that telehealth subsequent nursing facility 
care was previously provided on April 14, 2023. Nursing facility care services is one telehealth visit every 14 
days. 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 99307 billed for date of 
service April 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93978 billed for date of service December 
26, 2022.  
  You asked the Plan to pay for procedure code 93978. You say that modifier XS was appended to procedure 
code 93978 to show it was done different location and different encounter. The Plan denied your request. The 
Plan says payment for code 93978 is bundled into payment for code 93975. 
 
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 93978 
is a column II code to column I code 93975 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93978 billed for date of service December 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator (PNS) (64555 x2). 
 
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that this is medically necessary. The 
Plan denied your request. The Plan says the records show that the enrollee has polyneuropathy. Additionally, 
the enrollee has not had a psychological evaluation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that implantation of stimulators can be covered under specific 
conditions. 
 
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 peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the PNS device is experimental for polyneuropathy with multiple regions 
of symptoms. There is also no psychiatric evaluation. 
 
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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator (PNS) (64555 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliance (E0667) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device and segmental appliance. You say that the 
items should be covered. The Plan denied your request. The Plan says the records received do not indicate that 
the enrollee has an emergent or urgent medical condition, or are in need of specialized service(s) that are not 
available in the 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 
a pneumatic compression device (E0652) and segmental appliance (E0667) to be provided by an out-of-
network (OON) provider.