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 the enrollee just had back surgery and requires an 
IRF admission to regain mobility. The Plan denied your request. The Plan says the IRF services requested 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that this service is medically necessary and 
reasonable. The Plan denied your request. The Plan says the requested service 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 genicular nerve blocks. 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 literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied; the requested service is not 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 11, 2023, to 
February 9, 2023. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA as 
well as medical records to support payment. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
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. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 12, 2022. The NOA was not received by the Plan until April 27, 
2023. 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 home health services provided 
from January 11, 2023, to February 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 13, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
The CPT Code Manual definition of code 96521 is refilling and maintenance of a portable pump. We find that 
code 96521 is not supported. The records do not document that this service was performed. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 
13, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve ESI. You say that these services are medically necessary and reasonable. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of these 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 ESI. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has radicular referral pain of the upper cervical spine. The computed tomography 
(CT) of the C-spine shows neuroforminal stenosis. The request for ESI is medically necessary and appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ESI have been met. Therefore, we decided that the Plan has to pre-approve an 
epidural steroid injection (ESI).  
 
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 procedure code 96521 billed for date of service April 27, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed code is not supported. 
 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 96521 is refilling and maintenance of portable pump. We 
find that CPT code 96521 is not supported in the medical record. The medical records provided do not 
document the refilling and maintenance of a portable pump. 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 96521 billed for date of service April 27, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 You asked the Plan to pre-approve Hyalgan. You say that this medication is in stock, and the enrollee's quality 
of life would increase. The Plan denied your request. The Plan says that step therapy requirements have not 
been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Hyalgan. Our reviewer says that the 
step therapy requirements for this drug have not been met. Our physician reviewer found the Plan requires a 
trial of at least one of these alternatives: Monovisc, Synvisc One, or Orthovisc, before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network skilled nursing facility stay 
provided on October 01, 2021, to October 14, 2021. 
 
You asked the Plan to waive the copayment for an in-network skilled nursing facility stay. You say that this bill 
has been messy for a long time, and you just want it to be taken care of. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $184 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $184 copayment for an in-network skilled nursing facility stay. This item/service 
falls within the skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. You have been asked to pay a total of $1,840 for a skilled nursing 
facility stay ($184 copayment x 10 days = $1,840). You have not been charged for the day you were 
discharged. Therefore, we decided that the Plan does not have to waive the copayment for an in-network skilled 
nursing facility stay provided on October 01, 2021, to October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the request 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 you do not require treatment by multiple therapies at an intensive rehabilitation 
therapy program. There is no indication you would participate in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain functional status. Although you 
continue to have a need for skilled therapy, the documentation does not support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility.  You can receive further services at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77080 billed for date of service April 25, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the coding is appropriate. The Plan denied your 
request. The Plan says an appropriate diagnosis code was not reported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 77080 was billed with diagnosis code Z13.820. The claim was not billed with a 
diagnosis code suitable for payment. Based on this information, we decided that Medicare rules for coverage of 
the billed code have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
77080 billed for date of service April 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76706 billed for date of service April 20, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the enrollee's condition proved the medical 
necessity of the service. The Plan denied your request. The Plan says the diagnosis is inconsistent with the 
procedure. 
 
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 76706 is ultrasound, abdominal aorta, real time with 
image documentation, screening study for abdominal aortic aneurysm (AAA). We find that CPT code 76706 is 
not supported. The records do not show that the enrollee has one of the risk categories indicated for coverage. 
The claim was not billed with a primary diagnosis code suitable for payment. Based on this information, we 
decided that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76706 billed for date of service April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0500 and 99153 billed for date of service 
June 14, 2023. You asked the Plan to pay for the billed services. You say that the original claim was not fully processed. The 
Plan denied your request. The Plan says the billed codes are not supported. 
 
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 G0500 is moderate sedation services provided by the 
same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status. We find that CPT code G0500 is not supported in the 
medical record. Specifically, the records do not document an independent trained observer. Based on this 
information, we decided that Medicare rules for coverage have not been met. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting. We find that payment for CPT code 99153 
is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when 
performed in the facility setting. 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 
G0500 and 99153 billed for date of service June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 30, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for an 
LTACH placement. The Plan denied your request. The Plan says the LTACH services requested do 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 was admitted for scheduled hip arthroplasty that was complicated 
postoperatively by acute respiratory and renal failure. The record indicates that the enrollee is improving but 
still requires acute care services before transitioning to a lower level of care. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH facility. The 
requested service cannot be recommended, as the elements of the coverage rules are not satisfied. 
 
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 enrollee requires an IRF level of care for both 
physical and occupational therapy. The Plan denied your request. The Plan says the IRF services requested 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. Medically necessary care can 
be provided in a lower 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered on August 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from May 4, 2023, to May 18, 
2023. 
 
You asked the Plan to pay for the medical services. You say that you do not believe the patient was enrolled in 
hospice on the dates of service at issue. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 3, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
from May 4, 2023, to May 18, 2023.