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

 
We decided that the Plan does not have to pre-approve an ION facet screw spinal fixation implant. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
intervertebral disc degeneration of the lumbar region. He presented with lower back pain which has persisted 
for several months. The pain radiates to his hip when walking. However, detailed documentation is not evident 
regarding facet pathology with instability. Additionally, the request is not indicated for a stand-alone 
procedure. There is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. No compelling rationale is presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested posterior lateral arthrodesis with ION facet screw spinal fixation implant, in this case, is not 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ION facet screw spinal fixation implant.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatry genomic analysis panel (0345U) and MTHFR 
gene analysis (81291) provided on January 30, 2023. 
 
You asked the Plan to pay for the psychiatry genomic analysis panel and MTHFR gene analysis. You say that 
this testing was medically necessary. The Plan denied your request. The Plan says there was insufficient 
information provided to review this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the psychiatry genomic analysis panel 
and MTHFR gene analysis have been met. In this case the Plan needed medical records to review the medical 
necessity of these tests. Multiple requests for this information were sent by the Plan but the required 
documentation was not received. Without this information we are unable to review whether this testing was 
medically necessary. Therefore, we decided that the Plan does not have to pay for the psychiatry genomic 
analysis panel (0345U) and MTHFR gene analysis (81291) provided on January 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 10, 2022, to 
October 28, 2022 You asked the Plan to pay for the billed services. You say that the services rendered were medically necessary.  
The Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services.  
 
In this case, the start of care date is October 10, 2022. The NOA was not received by the Plan until November 
23, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from October 10, 2022, to October 28, 2022
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 at high risk for falls and further 
functional decline will result in re-hospitalization. The Plan denied your request. The Plan says based on the 
enrollee's care needs they could receive their care in a skilled nursing facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable. While the enrollee may benefit from physical and 
occupational therapy, their rehab needs can be provided in a lower intensity and alternate setting such a skilled 
nursing facility.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine polymerase chain reaction (PCR) Panel provided 
on October 11, 2022, and billed with codes 87481, 87511, 87496, 87529, 87532, 87641, 87651, 87653, 87661, 
and 87798. 
 
You asked the Plan to pay for the Urine PCR Panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based on this information, we decided that Medicare rules for coverage of the Urine PCR Panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the Urine polymerase chain reaction (PCR) Panel 
provided on October 11, 2022, and billed with codes 87481, 87511, 87496, 87529, 87532, 87641, 87651, 
87653, 87661, and 87798.
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 you are requesting an expedited 
reconsideration stating the enrollee's best chance for a quicker recovery and more favorable outcome will 
be with admission to the LTACH. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met.  
 
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 appears to be improving with treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and 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: 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 team of physicians and physical therapists that 
have been working with you recommend acute rehabilitation. You say rehabilitation will not only help you 
with mobility but help prepare your body quickly so you can start treatment to beat cancer. The Plan denied 
your request. The Plan says the 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 
You asked the Plan to pre-approve the ILR placement. You say that it is felt that this procedure is warranted. 
The Plan denied your request. The Plan says the procedure is not necessary as there is no history of syncope. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
memory loop recorder. 
 
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 ILR placement. Our reviewer says 
that the requested procedure is not medically reasonable and necessary.  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 ILR. As such, the medical necessity of this procedure is not supported. 
 
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 ILR placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve trial implantation of a spinal cord stimulator (63650, L8680). 
 
You asked the Plan to pre-approve implantation of a spinal cord stimulator. You say that the requested service 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested service is 
not medically necessary. 
 
The Plan follows Medicare rules. The rules say that no payment may be made for the implantation of dorsal 
column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions listed in the Medicare rules section of this letter have been 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 implantation of a spinal cord stimulator. 
Our reviewer says that the requested service is medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has chronic neck pain with radiation into the arms. The enrollee's medication 
trials have included Lyrica, topical Lidocaine, Tylenol with Codeine and Cymbalta. The enrollee has prior 
cervical fusion. The enrollee has had psychological evaluation and clearance. The enrollee meets all of the 
criteria for a spinal cord stimulator trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a spinal cord stimulator have been met. Therefore, we decided 
that the Plan has to pre-approve trial implantation of a spinal cord stimulator (63650, L8680).  
 
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 MAKOplasty for robotic assistance in the setting of 
total joint arthroplasty (20985 and 0055T) and two (2) inpatient hospital days. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. The Plan states the clinical value and 
effectiveness of MAKOplasty for robotic assistance in the setting of total joint arthroplasty has not been 
demonstrated in the peer-reviewed literature. 
 
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 pre-approve the 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 the review has determined that the record does not show that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department (ED) and/or observation care) would span two midnights. Furthermore, the current 
evidence-based medical literature does not support the routine use of computer-assisted navigated total joint 
arthroplasty over conventional total joint arthroplasty; therefore, the MAKOplasty is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MAKOplasty for robotic assistance in the setting of total joint arthroplasty (20985 and 
0055T) and two (2) inpatient hospital days.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiopulmonary exercise testing (CPET) and right 
heart catheterization (RHC). 
 
You asked the Plan to pre-approve the procedures. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the 
medically necessary criteria. 
 
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 procedures. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found review of the records provided fails to show the rationale for these studies. In summary, there is 
insufficient documentation to support the medical necessity for the requested CPET and RHC in this patient's 
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 the procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the cardiopulmonary exercise testing (CPET) and right heart catheterization (RHC).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient bilateral sacroiliac (SI) joint fusion 
(27279). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the claim should not have been 
denied because you have done all conservative treatments recommended. The Plan denied your request. The 
Plan says the requested surgery bilateral sacroiliac fusion 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 outpatient 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 imaging support for the performance of a sacroiliac joint fusion. The 
request is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient bilateral sacroiliac (SI) joint fusion (27279).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that sacral nerve stimulation is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that the enrollee has 
neurogenic bladder as a consequence of diabetes and stroke. This excludes coverage of sacral nerve stimulation 
per Medicare rules. 
 
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 pre-approve sacral nerve stimulation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service November 21, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says a panel cannot 
be billed as individual components.  
 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 panel testing was not billed with a single code as required. 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 the panel testing billed for date of service November 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found that there is no MRI scan showing only modic endplate changes and no facet 
degenerative 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 (64628, 64629).