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 are being discharged and are not able to provide 
for yourself at home because you cannot walk. You also say that you need 24 hour care and aggressive physical 
therapy. The Plan denied your request. The Plan says based on the available information, admission to IRF is 
not reasonable and necessary, as your condition does not meet the Medicare rules.  
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
gangrene, necrotizing fasciitis and a below the knee amputation. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do 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. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure for radiopharmaceutical localization 
(78808) provided on April 14, 2023. 
 
You asked the Plan to pay for the injection procedure. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says modifiers 26 and TC cannot be separately payable with 
codes billed in the outpatient hospital setting. 
 
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 78808 is injection procedure for radiopharmaceutical 
localization by non-imaging probe study, intravenous. 
 
We find that CPT code 78808 is not supported in the medical record. Specifically, technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are not separately payable to the 
lab. Per the Physician Fee Schedule, there is a Professional/Technical indicator of 5 for CPT code 78808. This 
means there is both a professional and technical component for this code and its not payable in the outpatient 
hospital setting. Based on this information, we decided that Medicare rules for coverage of the injection 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the injection 
procedure for radiopharmaceutical localization (78808) provided on April 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (x-ray) of the forearm and wrist 
billed with codes 73090 and 73110 provided on March 9, 2023. 
 
You asked the Plan to pay for the x-rays. You say that the services were billed correctly and should be paid. 
The Plan denied your request. The Plan says codes 73110 and 73090 are included in the facility payment and 
are not separately payable, as these codes were reported with modifier TC, which is paid by the facility. The 
claim was billed with Place of Service (POS) 23 which indicates that the enrollee was seen in a hospital 
emergency room. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Technical components must be billed by the 
facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab.  
The claim indicate that this service was provided to the enrollee while in an inpatient or outpatient facility. Per 
the Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 73110 and 73090. 
This means there is both a professional and technical component for these codes. In this case, an appropriate 
modifier to indicate the professional component (-26) has not been billed with CPT codes 73110 and 73090. 
Based on this information, we decided that Medicare rules for coverage of the x-rays have not been met. 
Therefore, we decided that the Plan does not have to pay for the radiologic examination (x-ray) of the forearm 
and wrist billed with codes 73090 and 73110 provided on March 9, 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 enrollee requires IRF services to regain their 
prior level of functioning and independence. The Plan denied your request. The Plan says you are appealing 
with supporting records.  
 
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 the enrollees 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services (97161, 97162, 97530, 97110) 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says you must use network providers to get 
your medical care and services. 
 
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 (97161, 97162, 97530, 97110) 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 lumbar radiofrequency ablation.  
You asked the Plan to pre-approve lumbar radiofrequency ablation. You say that lumbar radiofrequency 
ablation is medically necessary. The Plan denied your request. The Plan says due to Medicares frequency 
limitation noted to be at a covered spinal region and this member having already received 2 radiofrequency 
sessions at the same spinal region (L3-L5) within the last 12 months, the repeat procedure is not reasonable and 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar radiofrequency ablation is covered when the 
criteria listed in the Medicare rules section of this decision are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lumbar radiofrequency ablation. Our 
reviewer says that the requested lumbar radiofrequency ablation is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain. The enrollee 
has degenerative disc disease of the spine. The enrollee last underwent left sided lumbar radiofrequency 
ablation in May 2023, and right side in June 2023. The enrollee experienced over 50% relief of his axial low 
back pain for six months. The physician has ordered repeat radiofrequency ablation at the same spinal regions. 
The Medicare LCD limits radiofrequency ablation sessions to 2 per rolling 12 month period. The request 
exceeds the Medicare LCD utilization criteria of 2 sessions per rolling 12 month period. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar radiofrequency ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lumbar radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 11, 2022, to 
January 12, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that J18.9 is 
supported as the principal diagnosis and procedure code 5A1935Z is supported in the records, therefore the 
claim should be paid at the DRG originally billed. The Plan denied your request. The Plan says J18.9 is not a 
valid principal diagnosis code in this case. Records also do not support procedure code 5A1935Z. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
In this case, you billed the inpatient services provided with principal diagnosis code J18.9, defined as 
pneumonia, unspecified organism. Also billed on the claim was procedure code 5A1935Z, defined as 
ventilation, less than 24 consecutive hours. 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that procedure code 5A1935Z is not 
supported in the documentation, and diagnosis code J18.9 is not valid as a principal diagnosis in this case. Our 
physician reviewer found the enrollee was an 82-year-old who was treated in the hospital for suspected 
pneumonia and difficulty breathing. Chest x-ray showed mild infiltrate. They experienced cardiopulmonary 
arrest and were diagnosed with acute respiratory failure. Resuscitation efforts were initiated and terminated 
after twenty minutes. There was no record of the enrollee using ventilation support. Therefore, the 
documentation does not sufficiently support code 5A1935Z. Also, the acute respiratory failure would be the 
more appropriate principal diagnosis for this admission as it was the main reason for admission, with 
pneumonia as a secondary diagnosis. As such, code J18.9 is not valid as a principal diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 11, 2022, to January 12, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 admission is a medical necessity. The Plan denied 
your request. The Plan says based on the available information, admission to IRF is not reasonable and 
necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 
was admitted for surgical repair of a hip fracture after a fall. 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 and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 after your amputation your need rehabilitation in an 
IRF. Your care requirements cannot be adequately addressed in a lower level of care. 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: 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 to get her strength 
and endurance back. 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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. 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. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation 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: 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 admission to the IRF is a medical necessity. The 
Plan denied your request. The Plan says based on the available information, admission to IRF is not reasonable 
and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 
was admitted for hip pain and back pain. 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 and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 appealing the denial. The Plan denied your 
request. The Plan says that the enrollee's medical and therapy needs can be met in a skilled nursing unit.  
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. 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.  
 
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.