Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stereotactic body radiation therapy (SBRT) (77370 
and 77373). 
 
You asked the Plan to pre-approve the SBRT. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no good evidence the SBRT treatment is safe or effective or best for 
your cancer. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found given the poor prognosis and multi-focal nature of the disease, our physician reviewer's 
decision is unfavorable as SBRT for clinically diagnosed non-small cell lung cancer (NSCLC) would not be 
standard in the setting of multifocal disease for which only one (1) lesion is treated. 
 
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 SBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the stereotactic body radiation therapy (SBRT) (77370 and 77373).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vascular embolization or occlusion (37243). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is considered experimental and 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of genicular artery embolization in a patient who is status post (s/p) total knee 
arthroplasty is under study and is considered experimental at this time. It's role in osteoarthritis of the knee is 
also considered experimental. The request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the vascular embolization or occlusion (37243).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee's medical records to support the 
medically necessity for the Skilled Nursing Facility Services. The Plan denied your request. The Plan says 
based on the information received the enrollee did not meet the criteria for skilled nursing facility admission, 
services could be safely met at an alternate level, at an outpatient therapy or home care services 
 
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 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 and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
The enrollee has stabilized medically and is ready for discharge from the hospital.  The enrollee does not 
require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive 
further rehab services at a lower level of care.  Although further rehab services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or 
nutrition given via a feeding tube.  He is medically stable without any acute exacerbations of chronic medical 
problems.  His physical function is at or near his baseline and he can receive services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (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 the enrollee meets Medicare criteria for inpatient 
rehabilitation and will benefit from the rehabilitation that cannot be accomplished at a lower level of care. The 
Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such as a skilled nursing facility, home with home health services, or home with 
outpatient therapy. 
 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 was admitted for a femur fracture. 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, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. 
 
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 the FoundationOne Heme comprehensive genomic profiling 
tests (F1Heme) provided on July 12, 2022. 
 
You asked the Plan to pay for the FoundationOne Heme comprehensive genomic profiling tests (F1Heme). 
You say that the FoundationOne Heme was ordered by the treating physician because the test results were 
needed to help determine the course of treatment for this enrollee The Plan denied your request. The Plan says 
this lab service does not meet Medicare coverage criteria. 
 
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 pay for the FoundationOne Heme comprehensive 
genomic profiling tests (F1Heme). Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found this patient underwent 
molecular profiling (next generation sequencing (NGS)) with FoundationOne on bone marrow aspirate. The 
use of NGS for multiple myeloma is not considered a standard of care. The National Comprehensive Cancer 
Network (NCCN) Guidelines do not support the use of NGS for multiple myeloma treatment decision making. 
The service was not reasonable or 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 FoundationOne Heme comprehensive genomic profiling tests (F1Heme) 
have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme 
comprehensive genomic profiling tests (F1Heme) provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 37253 billed for date of service December 7, 2022. 
 
You asked the Plan to pay for code 37253. You say that this code was billed correctly and should be paid. The 
Plan denied your request. The Plan says code 37253 is not supported in the medical record. The operative 
report did not include documentation of intravascular ultrasound. 
 
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 37253 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel. 
 
 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 code 37253. Our reviewer says that code 37253 is not 
supported in the medical record. Our reviewer found the operative report does not describe per NCCI Policy "A 
needle is inserted through the skin and into a blood vessel. A guidewire is threaded through the needle into a 
noncoronary blood vessel. The needle is removed. An intravascular ultrasound catheter is placed over the 
guidewire. The ultrasound catheter is used to obtain images from inside the vessel to assess area and extent of 
disease prior to interventional therapy, as well as adequacy of therapy after interventional therapy". The 
operative report documents "The flush catheter was placed into the left common femoral artery. A left lower 
extremity runoff examination was performed. A 5-French sheath was advanced into the left common iliac 
artery. Catheter and guidewire were advanced through an occlusion of the profunda femoris and placed into the 
descending femoral branch of the profunda. IVUS of the left common iliac, external iliac, common femoral, 
profunda femoris, descending femoral branch of the profunda was performed." The documentation does not 
include enough information to confirm this procedure has been performed, and therefore 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 code 37253 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 37253 billed for date of service December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services (99223 and 99233) provided from 
September 8, 2022, through September 10, 2022. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. The definition of code 99233 is subsequent hospital care, per day, for the evaluation and management 
of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed 
examination; Medical decision making of high complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a 
significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the 
patient's hospital floor or unit. 
 
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 the documented physical 
findings for this date was broad, but not comprehensive. The enrollee was stable without evidence of severe or 
complex disease. The other two dates, notes described the enrollee with planned surgery, with difficulty 
sleeping and were brief, not detailed. Physical findings were also not detailed. There was insufficient support 
made in the provided documentation that any of these notes described a comprehensive or detailed history or 
physical, nor was there evidence of medical decision-making of high complexity. 
 
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 inpatient hospital services (99223 and 99233) provided from September 8, 2022, through 
September 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of the Sprint peripheral nerve stimulator 
(PNS). 
 
You asked the Plan to pre-approve the Sprint PNS placement. You say that it is felt that there is sufficient 
evidence to support the medical necessity of this service. The Plan denied your request. The Plan says this 
service is experimental at this time. 
 
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 Sprint PNS placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the role of Sprint PNS for the treatment of chronic low back pain is the 
subject of ongoing clinical trials. It remains an experimental therapy at this time, and therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Sprint PNS placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the placement of the Sprint peripheral nerve stimulator (PNS).
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 without rehab services the enrollee will not be able 
to regain proper function. The Plan denied your request. The Plan says the enrollee's care could be provided in 
a different setting. 
 
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 does not require treatment by multiple therapies. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 24, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill the claim as required by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The first home health 
visit reported on the claim was January 3, 2022, but there is not a Q-code provided to say where the service was performed. A required Q code to report where home health services were provided was not billed. Therefore, 
we decided that the Plan does not have to pay for the home health services provided on January 24, 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 the member meets full IRF criteria based on current 
condition and functional deficits. The Plan denied your request. The Plan says the IRF services request 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the superficial wound closure provided on October 25, 2022, 
billed with code 12001. 
 
You asked the Plan to pay for the superficial wound closure. You say that this was billed correctly because 
modifier -79 could not be used because the services were related to the procedure. There is no other global 
modifier that would be appropriate in this situation. The Plan denied your request. The Plan says this was not 
billed correctly as it was provided within the global period of a prior procedure.  
The Plan must follow Medicare rules. Medicare rules say that payment can be made separately for treatments 
for surgical complications which require a return to the operating room when modifier -78 is used.  
 
In this case, no modifier was reported to indicate that this service is separately payable within the global period. 
Therefore, we decided that the Plan does not have to pay for the superficial wound closure provided on October 
25, 2022, billed with code 12001.