Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk of infection or illness by 
staying in an acute facility. The Plan denied your request. The Plan says admission to an 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 that the complexity of the enrollees 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, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission for shoulder joint replacement surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says this procedure could be initially performed on an ambulatory/observation 
basis, and there is no need to prospectively approve the inpatient admission. 
 
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 acute inpatient hospital care. 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 the record does not show that at the time of inpatient admission, the admitting 
physician reasonable expected that the enrollees necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. Detailed documentation is not evident regarding a significant past 
and/or current medical history that would place this enrollee at increased risk for peri-surgical complications 
requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient admission for shoulder joint replacement surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your provider feels you would benefit from IRF 
services. The Plan denied your request. The Plan says admission to an 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service February 28, 
2023.  
 
You asked the Plan to pay for procedure code 84480. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 84480 is bundled into payment for code 84481. 
 
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 84480 
is a column II code to column I code 84481 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 84480 billed for date of service February 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37252, 37239, and 93770, billed for date of 
service May 2, 2022. 
 
You asked the Plan to pay for procedure codes 37252, 37239, and 93770. The Plan denied your request. The 
Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 37252 
is a column II code to column I code 37197. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
We also find that procedure code 93770 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 93770 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of procedure code 93770 have not been met. 
 
In this case, we have confirmed that code procedure code 37239 is an add-on code and has not been billed with 
an appropriate primary procedure code. 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 codes 37252, 37239, and 93770, 
billed for date of service May 2, 2022.
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 physical and occupational therapists and the 
physician state it is not safe for the enrollee to go home at this time. You say the enrollee needs skilled nursing 
to get stronger and after will go to assisted living. The Plan denied your request. The Plan says the SNF 
services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara System for Oscillation and Lung Expansion. 
 
You asked the Plan to pre-approve a Volara System. 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 high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Volara System. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the Volara System for Oscillation and Lung Expansion at issue in this 
case meets all of Medicare's LCD criteria for medically reasonable and necessary for the enrollee. Provided 
records in this case do not document the enrollee has a diagnosis of cystic fibrosis or bronchiectasis or a 
neuromuscular disease such as post-polio syndrome, multiple sclerosis or paralysis of the diaphragm, etc. 
 
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 Volara System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara System for Oscillation and Lung Expansion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve SPECT. You say that you have severe coronary artery calcification, and this 
service has been recommended by your physician. The Plan denied your request. The Plan says there is no 
evidence that you have symptoms of a heart problem or any abnormal heart tests; therefore, this imaging 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 SPECT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show no evidence that you have cardiac symptoms. There is no documentation that 
the electrocardiogram shows an uninterpretable pattern or that you are unable to exercise. There is no evidence 
provided that would support the need for radionuclide stress testing at this time. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in your 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient T12 and L1 Kyphoplasty (22513, 22514).  
 
You asked the Plan to pre-approve T12 and L1 Kyphoplasty. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says medical necessity coverage criteria is not met as the 
pain is multifactorial with multilevel disc disease in the spine.  
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty may be covered when the enrollee has 
painful, debilitating, osteoporotic vertebral collapse/compression fractures that have not responded to non-
surgical medical management with and without methods of immobility. 
 
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 T12 and L1 Kyphoplasty. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that there is no trial of a back 
brace. Trial of more conservative measures are needed to meet the criteria for coverage. Thus, this procedure is 
not medically reasonable and 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 T12 and L1 Kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve outpatient T12 and L1 Kyphoplasty (22513, 22514).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from 
September 29, 2021 to October 22, 2021. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. The documentation available 
for review that pertains to the appropriate look-back period does not support that the enrollees functional level 
and the nursing level of care were appropriately coded. The 1st and 3rd alphanumeric character in the PDPM 
were not correct. The partial adjustment to PDPM LDQC1 was appropriate. 
 
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 skilled nursing facility (SNF) services rendered from September 29, 2021 to October 22, 2021.
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 they have not done enough physical therapy, and 
you are not at your baseline of function. The Plan denied your request. The Plan says your request for approval 
of continued admission in the SNF does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the cervical spine.  
 
You asked the Plan to pre-approve a CT scan of the cervical spine. You say that you are appealing this denial.  
The Plan denied your request. The Plan says the requested CT scan is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the cervical spine. Our 
reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found there were 
no documented abnormalities of the cervical spine or any evidence of cervical radiculopathy. There has been 
no imaging of the cervical spine with plain films. There is no specific clinical rationale for a CT scan of the 
cervical spine. The requested CT scan is medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the cervical spine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT scan of the cervical spine.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that you have struggled with plantar fasciitis 
and would like the therapy to continue. The Plan denied your request. The Plan says the requested services are 
not medically reasonable and necessary. A re-evaluation with the provider has been 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 based on the records and the regulations, a period of 47 visits is 
sufficient treatment with electrical stimulation and ultrasound. The enrollee is able to perform a home exercise 
program. 
 
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 continued physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on January 16, 2023.  
 
You asked the Plan to pay for the medical services. You say that this was billed correctly for covered services.  
The Plan denied your request. The Plan says that there is a Medicare Learning Network (MLN) article which 
indicates that POS code 10 is not used by Medicare and that providers should bill in accordance with current 
telehealth guidelines, utilizing POS code 02.  
 
The Plan must follow Medicare rules. The rules say that Medicare must accept as valid any POS code from the 
national set when it is used on a claim. 
 
We looked at the file and Medicare rules. We reviewed the MLN article referenced by the Plan. While this does 
indicate that Medicare Administrative Contractors are to inform their providers that there is no need for the use 
of POS code 10, this article does not state that claims billed with this POS code should be denied. The claims 
processing rules cited above, which are based on the HIPAA rules, indicate that Medicare must accept any code 
from the set as valid. Since POS code 10 is officially in the POS code set, denial based solely on the POS code 
is not supported. Based on this information, we decided that Medicare rules for coverage of the medical 
services have been met. Therefore, we decided that the Plan has to pay for the medical services provided on 
January 16, 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.