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

 
We decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; 
placement of adjustable gastric restrictive device (43770). 
 
You asked the Plan to pre-approve laparoscopy, surgical, gastric restrictive procedure; placement of adjustable 
gastric restrictive device. You say that this is medically necessary. The Plan denied your request. The Plan says 
since your BMI is currently under 35 and your comorbidities are under control, a bariatric surgical procedure is 
not indicated. 
 
The Plan follows Medicare rules. Medicare rules say that bariatric surgery can be 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 laparoscopy, surgical, gastric restrictive 
procedure; placement of adjustable gastric restrictive device. Our reviewer says that you do not meet criteria 
for coverage. Our physician reviewer found you do not meet criteria for bariatric surgery based on your BMI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laparoscopy, surgical, gastric restrictive procedure; placement of adjustable 
gastric restrictive device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (43770).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
24, 2023. 
 
You asked the Plan to pay for the ED services. You say that the ED services should be paid as billed because 
the services were rendered in good faith. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acyclovir cream. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve acyclovir cream.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on January 03, 2023, to 
March 16, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that you are asking for the review of medical 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the outpatient services 
provided on January 03, 2023, to March 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee requires two more weeks of 
SNF care. The Plan denied your request. The Plan says they have already covered 100 days of SNF care during 
this benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 8, 2023, 
to January 8, 2024. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87651, 87798 and 87801 
billed for date of service September 7, 2023. 
 You asked the Plan to pay for procedure codes 87481, 87640, 87651, 87798 and 87801. You say that these 
services were necessary and are supported in the medical record. The Plan denied your request. The Plan says 
these codes are not supported 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 codes 87481, 87640, 87651 and 87798 are column II codes to column I 
code 87801; however, 87481, 87640, 87651 and 87798 were each billed with a modifier.  
 
We asked our coder 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 procedure codes 87481, 87640, 87651, 87798 and 87801. 
Our reviewer says that these codes are not supported as billed. Our reviewer found that the provider reported 3 
units of procedure code 87801; however, this code already reports multiple infectious agents and should be 
reported with one unit of service per methodology or test kit. The records provided do not support billing more 
than one unit of 87801 in this case. In addition, codes 87481, 87640, 87651 and 87798 are typically included in 
code 87801, but in this case, they were each billed with a modifier to report a separate, distinct service. 
However, the records provided do not support that the modifiers used were appropriate in this case. The 
laboratory report does not include sufficient documentation to support a rationale for separate billing in this 
case, and therefore modifier 59 and the separate reporting of these codes is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87640, 87651, 87798 and 87801 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87640, 87651, 87798 and 
87801 billed for date of service September 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to walk on your own. You require 
SNF services to regain your strength and prior level of functioning. The Plan denied your request. The Plan 
says the request is not medically necessary. 
 
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 that 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 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 a continuation of SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with transluminal angioplasty (37224). 
 
You asked the Plan to pre-approve revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), unilateral; with transluminal angioplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that peripheral revascularization can be 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 revascularization, endovascular, open 
or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. Our reviewer says that 
there is insufficient documentation to support the medical necessity for peripheral revascularization in this 
patient's clinical management. Our physician reviewer found the patient has evidence of lower extremity 
arterial disease, but the physician has indicated "no classical claudication and no pain or lesions involving the 
right or left foot." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), unilateral; with transluminal angioplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), 
unilateral; with transluminal angioplasty (37224).
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 LTACH is the most appropriate level 
of care for the enrollee who is stable and ready for transfer to the LTACH.  The Plan denied your request. The 
Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current 
hospital, and there are no issues for which the LTACH may offer a therapeutic advantage.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the health plan.  The documentation does not support that LTACH services are medically appropriate 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 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 you are requesting reconsideration for the denial of 
an IRF admission based on medical necessity. 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 the complexity of the enrollee's 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 genicular nerve blocks (64454 x2). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 genicular nerve blocks are experimental for knee pain. 
 
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 (64454 x2).
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 requested ILR procedure. You say that you are requesting 
reconsideration based on medical necessity. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria because they have not had episodes of syncope. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any significant 
cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. At this time, insertion of an ILR would not 
be considered medically appropriate and necessary in the enrollee'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 requested ILR procedure 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: 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 deconditioned and needs 
strengthening to increase function. You say this provides a more intensive program so that the enrollee can 
return to their prior level of function. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve PT visits. You say that this will cause undue stress and be more costly than 
being treated in the facility you live in. The Plan denied your request. The Plan says there are other providers 
available who are in-network, who are within the Medicare allowable distance from your residence. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve an ESI. You say that you are unable to stand up or walk on your own 
without the injection. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
criteria necessary for a repeat injection to be approved. 
 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 ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the LCD criteria requires 3 months of 50% or more pain relief. This criteria requirement was 
not achieved and therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health inpatient services provided on July 13, 
2022, to July 26th, 2022. 
 
You asked the Plan to pay for behavioral health inpatient services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for approval.  
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 behavioral health inpatient services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records provided 
for the admission of this enrollee does not meet criteria for acute inpatient mental health treatment as this 
enrollee was not shown to be a danger to himself or others. The enrollee at possible auditory no visual 
hallucinations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of behavioral health inpatient services have not been met. Therefore, we decided 
that the Plan does not have to pay for behavioral health inpatient services provided on July 13, 2022, to July 
26th, 2022.