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 require more aggressive therapy. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies as an 
outpatient or at a skilled nursing facility (SNF) may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not meet the coverage criteria for an IRF admission. You are medically stable 
and do not need medical monitoring by physical medicine and rehabilitation physicians with close supervision 
for conditions. You were getting daily physical and occupational therapy in the skilled nursing facility and are 
making slow progress. You need continued physical and occupational therapy, but do not need three hours a 
day five days a week of therapies with multidisciplinary approach in an IRF. Documentation does not support 
medical necessity for admission to an IRF. You have no medical complexity currently to warrant an admission 
to an IRF. While you would benefit from physical and occupational therapy, your rehabilitation needs can be 
safely provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
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 neurolytic destruction of genicular nerve branches 
(64624). 
 
You asked the Plan to pre-approve neurolytic destruction of genicular nerve branches. You say that the 
requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested service is experimental/investigational for 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 neurolytic destruction of genicular 
nerve branches. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has chronic knee pain. The indicated 
diagnosis is not an enumerated condition for which coverage is available for 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 neurolytic destruction of genicular nerve branches have not been met. 
Therefore, we decided that the Plan does not have to pre-approve neurolytic destruction of genicular nerve 
branches (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on July 21, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that the diagnoses billed are payable. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that I65.21 has an Excludes1 note in relation to G45.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services provided on July 21, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for units of procedure code 87481 rendered on May 6, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the documentation only supports three units of this code. 
 
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 87481 is "Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique." 
 
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 says that the services at issue in 
this case were supported by the medical records. Our reviewer found that four Candida species were tested for; 
one species was detected, three species were not detected. The health plan has only counted the three not 
detected species, not all tested for species. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
units of procedure code 87481 rendered on May 6, 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 percutaneous laminotomy/laminectomy (interlaminar 
approach) for decompression of neural elements, lumbar (0275T). 
 
You asked the Plan to pre-approve an outpatient surgery procedure. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are 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 an outpatient surgery procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication. He presented with low back pain. The lumbar epidural steroid injections provided a 
resolution of his radicular pain with an overall about 50% improvement. He continues to have sharp/achy low 
back pain with an inability to stand straight. The pain is rated at 8/10. The lumbar spine exam reveals a limited 
flexion. The strength is 5/5 in the bilateral lower extremities. Facet loading is positive. There are spasms and 
tenderness at the left lumbar. However, detailed documentation is not evident regarding this enrollee being 
enrolled in a clinical study that is approved by CMS. Therefore, the enrollee does not meet the coverage criteria 
detailed in the NCD. 
 
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 outpatient surgery procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for 
decompression of neural elements, lumbar (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a male vacuum erection system (L7900). 
 
You asked the Plan to pre-approve a vacuum erection system. You say that your private parts hurt, and your 
provider advised that if you do not get this condition fixed with this item, you will need surgery. The Plan 
denied your request. The Plan says the requested item is not a covered benefit under Medicare or your Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that a vacuum erection device is 
considered a prosthetic device under the prosthetic devices benefit category and is statutorily non-covered.  
 
While a vacuum erection system may be appropriate in this case, neither the Plan nor Medicare offers coverage 
of this item. Therefore, we decided that the Plan does not have to pre-approve a male vacuum erection system 
(L7900).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services with an out-of-network provider. You say that the 
services are necessary. The Plan denied your request. The Plan says the requested provider is out-of-network. 
There are in-network providers within the service area who can provide the same service. 
 
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 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 the office visit (99214) provided on May 16, 2023. 
 
You asked the Plan to pre-approve the physician service. You say that you should not be responsible for this 
bill. The Plan denied your request. The Plan says services required by a third party are not covered. 
 
The Plan follows Medicare rules. The rules say that examinations performed for a purpose other than treatment 
or diagnosis of a specific illness, symptoms, complaint, or injury (with the exception of a few tests listed in the 
Medicare rules section) are not covered. 
 
The records show that the examination in dispute was performed for the purpose of employment requirements. 
There is no evidence that the examination in dispute was performed for a purpose of treatment or diagnosis of a specific illness, symptoms, complaint, or injury. The examination in dispute was not one of the tests that 
Medicare covers for screening purposes. Therefore, we decided that the Plan does not have to pre-approve the 
office visit (99214) provided on May 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services (99285) provided on May 5, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making". 
 
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 says that the use of code 99285 is not supported by the records provided. Our reviewer found that a problem-focused history and physical were 
documented. However, the medical decision-making was not of high complexity.  As such, the billing of CPT 
99285 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency services (99285) provided on May 5, 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 you require IRF services and intensive rehabilitation 
to regain your 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 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
  You asked the Plan to pre-approve continued SNF care. You say that the enrollee has impaired functional 
mobility, including impaired balance and strength. You say that the enrollee needs skilled treatment five times 
a week. The Plan denied your request. The Plan says continued SNF services are 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 continued 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 have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee does not require daily skilled nursing 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
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 a fall risk and need IRF services to improve 
your 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 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 38747-59 rendered on March 27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 38747-59 is considered inclusive to CPT 48150. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure report does include documentation of abdominal lymphadenectomy. However, the edits restrict 
billing CPT codes 48150-48154 with CPT 38747. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 38747-59 rendered on March 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a LTACH 
admission to get the rehabilitation they need and recover faster. The Plan denied your request. The Plan says 
the request is not medically necessary. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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 provided records show that the enrollee's medical conditions appear improved on 
stable medication with no issues that appear to require a physician's evaluation three or more times per week in 
a hospital setting. The enrollee does require physical therapy and occupational therapy services, but the medical 
records provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. 
Provided medical records do not support that the intensive rehabilitation therapy program is necessary and that 
therapy at a lower level of care such as in a skilled nursing facility (SNF) is not appropriate for the enrollee. 
The enrollee would be expected to participate in and benefit from the intensive rehabilitation therapy program 
provided in the IRF, however, the medical records do not support a complexity of needs to require an IRF with 
an interdisciplinary team over a SNF.  
 
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.