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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show the rehabilitation needs are 
complex. The Plan says that the services needed may be provided safely in a lower 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 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. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says criteria for acute inpatient rehabilitation based on Medicare 
guideline were not met. The Plan says that the services needed may be provided safely in a lower 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 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. 
 
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 pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee's health is deteriorating and getting 
weaker and weaker, needs medication to be administered and is in pain all the time. The Plan denied your 
request. The Plan says the enrollee's records does not show the need for daily skilled nursing or skilled therapy 
in a SNF setting. Services can safely be received at a different setting, continuing with home health, in 
residential care, or home with close follow-up with physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure at L2-L3 and L3-L4. 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the enrollee would benefit from light 
sedation, which can be done with a Vertiflex. The Plan denied your request. The Plan says this procedure is 
considered 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 a Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental, and more research is needed. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure at L2-L3 and L3-L4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device (E0601) a heated humidifier (E0562) and supplies (A7035, A7036, A7030, A7037, A7039, 
A7031, A7032, A7033, A7038). 
 
You asked the Plan to pre-approve continued use of a CPAP device and supplies. You say that you disagree 
with the denial and request reconsideration. The Plan denied your request. The Plan says you do not meet 
criteria for approval of the device and supplies. 
 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 continued use of a CPAP device and 
supplies. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found provided records in this case do not document adequate 
compliance with use of the CPAP device to meet Medicare and LCD criteria for continued coverage for the 
CPAP device. The LCD requires objective evidence of adherence to use of the CPAP device, reviewed by the 
treating practitioner. Adherence to therapy is defined as use of CPAP =4 hours per night on 70% of nights 
during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. In this 
case, records show 0% use of the CPAP device for 4 or more hours per night from February 26, 2023, through 
May 26, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a CPAP device and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device (E0601) a heated humidifier (E0562) and supplies (A7035, A7036, A7030, A7037, A7039, 
A7031, A7032, A7033, A7038).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 21, 
2022, through December 22, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
 
 
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that you presented to the emergency department (ED) with nausea, vomiting, abdominal 
cramping, and diarrhea following having a week of influenza. The exam was unremarkable with a non-tender 
abdomen. The workup revealed elevated procalcitonin and leukocytosis. You were started on antibiotics and 
fluids. You did not require surgery or intravenous medications. Your vital signs were stable. Based on the 
provided documentation prior to admission, it was not expected that you would have required hospital care that 
would have likely crossed two midnights.  
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from December 21, 2022, through December 22, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the echocardiogram interpretation services described by code 93306-26 
performed on March 1, 2023. 
 
You asked the Plan to pay for the echocardiogram interpretation services. You say that the echocardiogram 
interpretation services should be covered as billed because they were medically necessary and are supported in 
the records. The Plan denied your request. The Plan says that the date of service for the echocardiogram 
interpretation services cannot be verified because records show the study date is listed as March 1, 2023, and 
the review date is listed as February 28, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures should be reported with the CPT code 
that describes the services performed. 
 
We looked at the file and Medicare rules. On the echocardiogram report provided, the date of the study is 
actually listed as February 28, 2023, and the review date is listed as March 1, 2023. The claim for the 
echocardiogram interpretation services was billed with date of service March 1, 2023, which matches the date 
of review on the procedure report. Therefore, records are consistent that the date of service for the 
echocardiogram interpretation services was March 1, 2023. Based on this information, we decided that 
Medicare rules for coverage of the echocardiogram interpretation services have been met. Therefore, we 
decided that the Plan has to pay for the echocardiogram interpretation services described by code 93306-26 
performed on March 1, 2023.  
 
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 genetic testing provided on March 29, 2023, billed with 
codes 81270, 81279, 81338, 81219, and G0452-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the 
claim. Code G0452 was not billed with the required modifier and is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The rules also say that providers must report services correctly. Technical 
components must be billed by the facility where the enrollee was an inpatient or outpatient and are not 
separately payable to the lab. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Also, code G0452 was not billed with the required modifier to indicate the professional component 
for this code. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on March 29, 2023, billed with codes 81270, 81279, 81338, 81219, and G0452-59.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Procedure. 
 
You asked the Plan to pre-approve an Intracept Procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. 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 an Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or foraminal stenosis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept Procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee requires continued skilled 
care and is unable to be trained to caregiver due to skilled service necessary for modifications and prolonging 
functional mobility through disease progression. The Plan denied your request. The Plan says the enrollee 
received 46 sessions of therapy with minimal improvement in your function and has not had a recent injury or illness. The requested 16 additional visits - four were approved on initial review to establish a home 
maintenance program, remaining 12 are still not approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there is no evidence continued unique input from a skilled therapist is 
necessary. The physical therapy notes do not indicate a reason for continued skilled therapy based on response 
to previous therapy the notes also do not show adjustment or input from the therapist beyond repetitive 
exercise. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 physical therapy visits
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral breast reduction. 
 
You asked the Plan to pre-approve a bilateral breast reduction. You say that the enrollee complains of neck and 
shoulder pain. The Plan denied your request. The Plan says the enrollee has not tried more conservative 
measures such as physical therapy, pain medication, or supportive bras. 
 
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 bilateral breast reduction. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient documentation that this enrollee has significant 
symptoms that have interfered with normal daily activities, despite conservative management, for at least 6 
months. 
 
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 bilateral breast reduction have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bilateral breast reduction.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for  practitioner services provided on April 27, 2023, billed with evaluation 
and management (EM) code 99223-AI. 
 
You asked the Plan to pay for  the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the claim was billed with an inappropriate 
place of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that the place of service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face-to-face service. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the specific denial rationale provided by the Plan is not supported. 
The Plan states that this claim was inappropriately billed with place of service 21. However, we have verified 
that this claim was billed with place of service code 22. Documentation shows that the enrollee was in 
outpatient observation on this date of service. As such the Plans denial of this claim is not substantiated. 
Therefore, we decided that the Plan has to pay for  practitioner services provided on April 27, 2023, billed with 
evaluation and management (EM) code 99223-AI.  
 
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. The Plan denied your request. The Plan says your records do not 
show that your rehabilitation needs are complex. The Plan says that the services needed may be provided safely 
in a lower 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested item is a necessity 
for the enrollee's care. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that a semi-electric hospital bed is not medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that the enrollee has a condition that requires 
frequent positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent 
contractures or avoid respiratory infections in a way that an ordinary bed is not able to. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).