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 you would like to get back to a baseline before going 
back home. The Plan denied your request. The Plan says that admission to an IRF is not medically necessary 
and does not meet the criteria for coverage.  
 
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 can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided 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 codes 99233, 99232, 99291 provided May 5, 
2023, through May 7, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  

The definition of code 99232 is subsequent hospital inpatient or observation care, per day, for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. When using total time on the date of the encounter for code selection, 35 
minutes must be met or exceeded. The definition of code 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
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 the services. Our reviewer found for code 99291 provided 
May 5, 2023, it does not meet criteria for billing or reimbursement consideration. The medical records provided 
does not include a critical care evaluation and management note for May 5, 2023; therefore, this service cannot 
be verified. For code 99232 provided May 6, 2023, it does not meet criteria for billing or reimbursement 
consideration. The medical records provided does not include sufficient documentation to validate that the 
provider provided this service on May 6, 2023; therefore, this service cannot be reimbursed. For code 99233 
provided May 7, 2023, it does not meet criteria for billing or reimbursement consideration. The medical records 
provided does not include total time spent for the encounter on May 7, 2023, and does not support a high level 
of medical decision making; therefore, this service cannot be verified 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99233, 99232, 99291 provided May 5, 2023, through May 7, 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 these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is currently receiving the appropriate 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 that over six days, the enrollee was weaned down from high flow oxygen. The 
enrollee is only tolerating two hours in a chair due to activity intolerance associated with prolonged illness and 
hospitalization. While on high-flow nasal cannula (HFNC), the enrollee is not stable for transfer. 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Gammagard Liquid. 
 
You asked the Plan to pre-approve the medication. You say that the Gammagard Liquid is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the use 
of Gammagard Liquid. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 
 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 medication. Our reviewer says that 
the elements of the coverage criteria are not satisfied. The requested service cannot be recommended. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of unspecified myopathy. The 
FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved 
drug compendia does not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The record provided is insufficient to establish that the enumerated requirements of the coverage 
article are satisfied.  The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Gammagard Liquid.
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 the enrollee needs to have the 
current monitor replaced as the battery life is very limited and would not work in the upcoming days. The Plan 
denied your request. The Plan says an insertion of a loop monitor is not medically necessary.  
 
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 that the enrollee has a history of strokes and documented arterial flutter, 
with previous insertion of ILR which is not at the end of service, However, based on current guidelines and the 
documentation provided, there is insufficient clinical evidence to support the medical appropriateness and 
necessity of replacing the patient's old ILR with a new ILR. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the enrollee has had 
prior injections with only sustaining 30-40% pain relief. However, the LCD coverage criteria requires 50% 
improvement for three months which was not achieved. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the criteria for SNF care has not been met. 
 
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 the enrollee does not require daily skilled nursing services. The enrollee does require 
therapy services, however there are no records that show he needs daily inpatient skilled therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87551, 87556, 87561, 87640, 87641, 
87651, 87653 and 87798 billed for date of service May 6, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87551, 87556, 87561, 87640, 87641, 87651, 87653 and 
87798. You say that you have billed the services at issue correctly. The Plan denied your request. The Plan says 
payment for codes 87481, 87551, 87556, 87561, 87640, 87641, 87651, 87653 and 87798 is bundled into 
payment for code 87801. 
 
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, 87551, 87556, 87561, 87640, 87641, 87651, 87653 and 
87798 are column II codes to column I code 87801; however, 87481, 87551, 87556, 87561, 87640, 87641, 
87651, 87653 and 87798 were 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, 87551, 87556, 87561, 87640, 87641, 
87651, 87653 and 87798. Our reviewer says that procedure codes 87481, 87551, 87556, 87561, 87640, 87641, 
87651, 87653 and 87798 do not meet criteria for payment. Our reviewer found that the rules allow for the use 
of a modifier to unbundle the relationship between 87801 and the codes at issue, providing the medical records 
support the use of an appropriate modifier. In this case, the medical records do not support that the codes at 
issue were performed as distinct, independent procedures; therefore, these services cannot be verified. 
 
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, 87551, 87556, 87561, 87640, 87641, 87651, 87653 and 
87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 
87551, 87556, 87561, 87640, 87641, 87651, 87653 and 87798 billed for date of service May 6, 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 requires wound care. The 
Plan denied your request. The Plan says the enrollee's medical issues can safely be managed at a lower level of 
care such as subacute rehabilitation. 
 
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 with head and neck cancer for scheduled operative 
intervention. 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 elements of the coverage rules are not 
satisfied.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you need this injection as soon as 
possible as the pain is too severe which is keeping you from being able to get you some good sleep. The Plan 
denied your request. The Plan says the genicular nerve block is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered experimental and investigational therapy. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on September 5, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that on August 30, 2023 you experienced 
pain and looseness in your tooth so you saw the dentist the following day and were told you needed a root 
canal. You also say that you were referred to a dentist for an extraction and feel the evaluation is justifiable to 
perform the surgery. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on dates of service August 31, 2023, and 
September 1, 2023. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - 
problem focused (D0140) provided on September 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84402, 84403, 84550, 85651, 86003, and 
86431 billed for date of service April 10, 2023. 

You asked the Plan to pay for the billed testing. 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 84402 is testosterone; free. The definition of code 84403 
is testosterone; total. The definition of code 84550 is uric acid; blood. The definition of code 85651 is 
sedimentation rate, erythrocyte; non-automated. The definition of code 86003 is allergen specific IgE; 
quantitative or semiquantitative, crude allergen extract, each. The definition of code 86431 is rheumatoid 
factor; quantitative.  
 
We find that CPT codes 84402, 84403, 84550, 85651, 86003, and 86431 are not supported in the medical 
record. The records provided do not show that the treating physician ordered the testing at issue. Based on this 
information, we decided that Medicare rules for coverage of the billed testing have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 84402, 84403, 84550, 85651, 86003, and 86431 
billed for date of service April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Clarifix procedure (C9771). 
 
You asked the Plan to pre-approve the Clarifix procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says this procedure has not been shown to be effective in treating the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Clarifix procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is insufficient literature to support the safety and efficacy of the requested 
service for the enrollee's specific conditions. 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 the Clarifix procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Clarifix procedure (C9771).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90792 for date of service  
 
You asked the Plan to pay for procedure code 90792. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 90792 is psychiatric diagnostic evaluation with medical 
services. 
 
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 code 90792. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the medical record does not include 
sufficient documentation to support psychotherapy to include treatment plan. Psychiatric Diagnostic Interview Examination require the following: Elicitation of a complete medical and psychiatric history; Mental status 
examination; Establishment of an initial diagnosis; Evaluation of the patient's ability and capacity to respond to 
treatment; Initial plan of treatment. This was not found in medical report and cannot be verified. Therefore, 
code 90792 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 code 90792 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 90792 for date of service