Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services. You say that the medical records provided support 
the need for the requested home health physical therapy visits. The Plan denied your request. The Plan says that 
the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that the enrollee has a medical history of spinal fusion, multiple sclerosis with multiple 
falls and peripheral neuropathy. The enrollee continues to require contact guard assist with mobility tasks and 
has not met all appropriate physical therapy goals and still requiring medical equipment evaluation thus the 
record shows that 6 additional home health skilled therapy visits are required to effectively provide treatment, 
care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance 
program to maintain the enrollee's level of function and/or prevent deterioration. 
 
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 home health services have been met. Therefore, we decided that the Plan has 
to pre-approve home health services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs this. 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 Ozempic.  
 
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 pre-approve genicular nerve radiofrequency ablation procedure. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation procedure. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is considered investigational and not 
medically necessary for the treatment of chronic knee pain. 
 
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 radiofrequency ablation 
procedure. 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 and genicular nerve 
radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic 
knee pain. The review has determined that the requested genicular nerve radiofrequency ablation of the left knee 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 genicular nerve radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation 
procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214-25 billed for date of service July 31, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the code is 
included in the payment for other services. 
 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 99214-25 is not. Code 99214 was billed along with codes 95886 and 95911. Codes 
95886 and 95911 are not surgical or endoscopic procedures. There are no code edits between code 99214 and 
either of the other codes. Modifier -25 was incorrectly appended to the code at issue. 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 99214-25 billed for date of service July 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of lower spine. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found there are no red flags or prior trial of physical 
therapy to establish medical necessity of the MRI at this time. The criterion for approval has not been met. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of lower spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 29, 2023. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the documentation submitted does not include a valid physician order for 
this specific testing. 
 The Plan must follow Medicare rules. Medicare rules say that all diagnostic laboratory tests must be ordered by 
the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid lab order for 
the specific lab code billed on this claim. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing provided on June 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0070) 
provided on APril 18, 2023. 
 
You asked the Plan to pay for the transportation of portable x-ray equipment . You say that the service was 
medically necessary. The Plan denied your request. The Plan says the records do not document that the x-ray 
equipment was transported to the facility where the services took place. 
 
The Plan must follow Medicare rules. Medicare rules say that no transportation charge is payable unless the 
portable x-ray equipment used was actually transported to the location where the x-ray was taken. For example, 
Medicare does  not allow a transportation charge when the x-ray equipment is stored in a nursing home for use 
as needed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transportation of portable x-ray equipment  have not been met. Specifically, the records do not document that the x-ray equipment was transported to the facility where the services took place. Therefore, we 
decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0070) provided 
on APril 18, 2023.
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 inpatient rehabilitation facility services are 
medically necessary. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided at a lower level of care.  
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies 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. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (codes 81314, 81345) provided on 
February 27, 2023. 
 You asked the Plan to pay for 81314 and 81345. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says these genes were assayed in parallel so should be billed with a single 
panel code. 
 
The Plan follows Medicare rules. Medicare rules state that if a laboratory assays 2 or more genes in parallel, 1 
procedure code must be submitted. 
 
We asked our coding 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 81314 and 81345. Our reviewer says that 
these codes do not meet criteria for payment. Our coding reviewer found the services billed do not meet 
Medicare criteria.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 81314 and 81345 have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory testing (codes 81314, 81345) provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological and neuropsychological tests. 
 
You asked the Plan to pre-approve psychological and neuropsychological tests. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says  psychological testing 
requires a clinically trained examiner. All psychological tests should be administered, scored, and interpreted 
by a trained professional such as a clinical psychologist, psychologist, advanced nurse practitioner with 
education in this area, or a physician assistant who works with a psychiatrist with expertise in the appropriate 
area. The pain management specialist is not credentialed to provide these services.  
 
The Plan follows Medicare rules. Medicare rules say that when there are deficits on standard mental status 
testing or clinical interview, and a neuropsychological assessment is needed to establish the presence of 
abnormalities or distinguish them from other disease processes. 
 
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 psychological and neuropsychological 
tests. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided records indicate the assessing clinician in this case is trained in anesthesiology and pain medicine but not in 
psychology or psychiatry.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological and neuropsychological tests have not been met. Therefore, we 
decided that the Plan does not have to pre-approve psychological and neuropsychological tests.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. You say that you would like this wheelchair to be approved so the patient is able to use the 
wheelchair. The Plan denied your request. The Plan says although there are three approved power options on 
this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options 
through the joystick. 
 
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 electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that this request is not medically necessary. 
Our physician reviewer found the patient had stroke in 2017 impacting their left side. There is no evaluation of 
the patient's right side and no evidence of quadriplegia. Our reviewer also found that the patient has adequate 
strength to manage standard power drives. 
 
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 electronic connection, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), and expandable controller (E2377).
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 had a stroke and you need physical, speech and 
occupational therapy, as well as assistance to do everything you would normally do in your everyday life. The 
Plan denied your request. The Plan says you do not meet the medical necessity criteria.  
 
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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the full cost for the chiropractic manipulative treatment 
(98940) provided by a chiropractor on July 11, 2023. 
 
You asked the Plan to pay for the full cost for the chiropractic manipulative treatment (98940). You say that 
you went in to get chiropractic services done and it should have been covered. The Plan denied your request. 
The Plan says the chiropractic manipulative treatment processed correctly with a $20 copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
You have been asked to pay a $20 copayment for the chiropractic manipulative treatment (98940). This 
item/service falls within the Chiropractic Services 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. Therefore, we decided that the Plan does not have to pay for the 
full cost for the chiropractic manipulative treatment (98940) provided by a chiropractor on July 11, 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 you would like to request 
reconsideration of the denied LTACH services and that the services requested are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 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 requested IRF services are necessary for the 
enrollee to regain their strength and go home. The Plan denied your request. The Plan says the records do not 
show that the enrollee needs to be seen by a rehabilitation doctor at least three times a week for evaluation of 
functional and medical goals.  
 
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. The enrollee's 
medical problems are stable. 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. 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. 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.