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 meets the full criteria for an inpatient 
acute rehabilitation stay, which is needed to maximize the enrollee's potential to return to their previous level of 
independence. The Plan denied your request. The Plan says based on Medicare guidelines, 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee would benefit with this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a history 
of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve destruction. 
 
You asked the Plan to pre-approve genicular nerve destruction. You say that this is needed for further and long-
lasting pain relief. The Plan denied your request. The Plan says this procedure is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve destruction. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental/investigational 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 genicular nerve destruction have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve destruction.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right heart catheterization (93460). 
 
You asked the Plan to pre-approve right heart catheterization. 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 right heart catheterization 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 right heart catheterization. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee with normal 
noninvasive workup does not benefit from the suggested invasive studies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve right heart catheterization (93460).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PILD procedure (0275T). 
 
You asked the Plan to pre-approve a PILD procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of a PILD procedure 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered when provided in a clinical 
study through CED for beneficiaries with LSS who are enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PILD procedure have not been met. Specifically, there is no indication in the case record that the 
enrollee is participating in an approved clinical study. Therefore, we decided that the Plan does not have to pre-
approve a PILD procedure (0275T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 5, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 laboratory services have been met. 
Specifically, the records include a physician order; however, this order is not clear on what tests with procedure 
codes are being ordered. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on October 17, 2022. 
 
You asked the Plan to pay for telehealth services. You say that the doctor provided service to the member in 
good faith and should be reimbursed for their services. The Plan denied your request. The Plan says virtual care 
is not covered out-of-network. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care services 
out-of-network. Based on this information, we decided that the Plans rules for coverage of the telehealth 
services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit for allergen immunotherapy services provided on 
January 13, 2023. 
 
You asked the Plan to pay for the office visit for allergen immunotherapy services. You say that the services 
this physician is providing is lifesaving, and you cannot go without these services. The Plan denied your 
request. The Plan says that items or services furnished by a provider who has opted-out of participation with 
Medicare. An opt-out provider cannot bill us, nor can we pay you for these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided proof that this provider has opted out of 
Medicare. Therefore, we decided that the Plan has to pay for an office visit for allergen immunotherapy 
services provided on January 13, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy and hospital inpatient admission 
(15830). 
 
You asked the Plan to pre-approve panniculectomy and hospital inpatient admission. 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 panniculectomy and hospital inpatient 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record provided does not document the presence of 
chronic intertrigo refractory to conservative treatment or functional impairment. The pannus does not extend beneath the pubic symphysis. 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 panniculectomy and hospital inpatient admission have not been met. Therefore, 
we decided that the Plan does not have to pre-approve panniculectomy and hospital inpatient admission 
(15830).
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet all the requirements. The Plan 
says that the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring treatment management 
services (99457) and remote monitoring of physiologic parameters (99454) provided on January 16, 2023, to 
February 28, 2023, by an out-of-network (OON) provider.   
You asked the Plan to pay for the physician services. You say that the services were rendered to the enrollee in 
good faith. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the remote physiologic monitoring treatment 
management services (99457) and remote monitoring of physiologic parameters (99454) provided on January 
16, 2023, to February 28, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 9, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation provided on April 25, 2023. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says the denial is 
maintained because the supplier is not contracted for official transport, there is no prior authorization, and no 
medical evidence of life at risk. 
 
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 transportation have been met. 
enough information was not provided to show what sort of transportation was actually provided, or that the 
transportation provided was medical in any way. The records also do not show that the rendering provider is a 
medical provider. Therefore, we decided that the Plan does not have to pay for the transportation provided on 
April 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Minuteman G3R interspinous device 
(22612, 20930, 22840). 
 
You asked the Plan to pre-approve a Minuteman G3R device. 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 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Minuteman G3R device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Minuteman device is experimental. More research is needed to 
demonstrate its safety and efficacy.  
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 Minuteman G3R device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a Minuteman G3R interspinous device (22612, 20930, 22840).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SI joint) fusion (27279). 
 
You asked the Plan to pre-approve SI joint fusion. 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 minimally-invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint is considered medically necessary when certain 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 SI joint fusion. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no SI joint instability, fracture 
or lesion. SI joint fusion for degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint (SI joint) fusion (27279).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 18, 2022, 
December 2, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of 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 November 18, 2022. The NOA was not received by the Plan until January 
11, 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 the home health services 
provided from November 18, 2022, December 2, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment billed with code G2067 
provided from December 5, 2022, to December 26, 2022. 
 
You asked the Plan to pay for procedure code G2067. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Section 1833 (s)(2)(HH)(jjj))) of the Act recognizes Free-Standing 
Opioid Treatment Program Facilities as "providers of services" but only for furnishing Opioid Treatment 
Program services. Applicable provider ranges are xx9900-xx9999 billed on a claim with a type of bill 087x. The file shows that the Plan confirmed that the provider is a free-standing clinic who is eligible to be 
reimbursed for covered services; however, the provider submitted the appealed claim with type of bill 131 
incorrectly and without the applicable provider ranges. Therefore, we decided that the Plan does not have to 
pay for the medication assisted treatment billed with code G2067 provided from December 5, 2022, to 
December 26, 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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's condition 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  There are no 
complex nursing or rehabilitation needs.  
 
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 
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 acute inpatient rehabilitation facility (IRF) admission and services.