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 the enrollee is de conditioning and not progressing 
towards baseline and is eagerly requesting a transfer to an IRF for proper physician care. The Plan denied your 
request. The Plan says the enrollee's condition does not meet the Medicare guidelines. The Plan says that the 
services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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.  
 
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 is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show the rehabilitation needs are 
complex. The Plan says that the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vehicle trailer for a scooter. 
 
You asked the Plan to pre-approve a vehicle trailer for a scooter. You say that you need a trailer to pull your 
scooter because you have a front wheel compact car. The Plan denied your request. The Plan says this item is 
not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although 
this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, 
we decided that the Plan does not have to pre-approve a vehicle trailer for a scooter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve the requested services. You say that cognitive testing is an indispensable 
tool for prescribing opioids. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is only covered under 
certain medical indications. 
 
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 services. Our physician 
reviewer found that neuropsychological testing is considered medically necessary when there are deficits on 
standard mental status testing or clinical interview, and a neuropsychological assessment is needed to establish 
the presence of abnormalities or distinguish them from other disease processes. In this case, the documentation 
does not support that the enrollee has had significant complaints of cognitive impairment with abnormal 
findings on screening tests that would necessitate formal neuropsychological testing. Therefore, the requested 
services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve neuropsychological testing.
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. The Plan denied your request. The Plan says the enrollee does not 
require daily skilled services on an inpatient basis at the SNF level of care. The Plan says that the services 
needed may be custodial care.  
 
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. 
 
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not  meet all of the requirements. The 
Plan says that the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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.  
 
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 L3 percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee is experiencing pain and would 
benefit from this procedure. The Plan denied your request. The Plan says this 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no trial of back fracture bracing. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L3 percutaneous vertebral augmentation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the enrollee needs to continue 
physical therapy for their low back pain. The Plan denied your request. The Plan says that the 10 additional 
physical therapy visits are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee does not require the unique skills of 
a professional therapist to safely and effectively provide treatment. The services can be safely and effectively 
performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design, or deliver a program to maintain the enrollee's current condition to prevent or slow further 
deterioration.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 22830. We decided that the Plan does not have to pay for 22849.   
You asked the Plan to pay for procedure codes 22830 and 22842 rendered on January 27, 2023.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 22830.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 22830 is "Exploration of 
spinal fusion." 
 
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 for CPT 22830. Our reviewer says that CPT 22830 was 
performed at L2-L3. CPT 22610 is for thoracic fusion, which is at a different spinal level. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
22830.  
 
We also decided that the Plan does not have to pay for 22849. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of  CPT 22849 is "Posterior 
segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 
vertebral segments (List separately in addition to code for primary procedure)." 
 
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 for CPT 22849. Our reviewer says that this code is for 
rod removal. This is included in CPT 22842 with instrumentation for 3-6 segments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 22849 have not been met. Therefore, we decided that the Plan does not have to 
pay for 22849. 
 
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: 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 services are medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says  
Skip Navigation  
 My Account  
 Change Role  
 Sign Out   Help  
QIC 1.0 - 49820 (Manager)  
 Home  
 Tracking Inbox  
o Appeal  
o Document Management  
o MD ID Information  
o Mas Webservice Status  
o Team Skill Sets  
 Search  
 Administration  
Tracking Inbox  Appeal (1-13208519243)  Parties Listing  
Party Listing  
Appeal Number: 1-13208519243 
Appeal Deadline Date: 10/29/2023 12:00 AM 
Part: Part C 
Last Name: Joyner 
Appeal Type: Supplemental Benefit 
Dates of Service: 03/07/2023 to 03/07/2023 
Decision:  
Status: Ready For Triage 
Aged: 17 
 Appeal  
o New Appeal  
 Parties  
o New Parties  
 Claims  
o New Claims  
 Documentation  
o New Documentation  
 Notes  
o New Notes  
 Medical Review  
 Related Appeals  
 Transition Log  
o New Transition Log  
 Decision QC Review  
o New Decision QC Review  
 Assignments  
o New Assignment  
Assignment: No Assignment  
 New  
 Print  
 CSV    Party 
Type 
Appella
nt 
Request
or 
Last 
Nam
e 
First 
Nam
e 
HI
C # 
Medicare 
Number 
Organizati
on 
Addres
s Line 1 
Addre
ss Line 
2 
City 
Stat
e 
Zip 
 
Plan  
       
XERO
X ACS 
ATTN 
April 
Golacke
y  
2432 
Fortun
e Drive 
#120  
Lexingto
n  
KY  
4050
9  
 
Beneficia
ry  
Yes  Yes  
Joyne
r  
Steve
n  
 
7J51D71MM
93  
 
1062 
SILVE
R 
GULL 
DR  
 
TEGA 
CAY  
SC  
2970
8  
 
  
 
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: 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 services are medically necessary for your therapy 
needs. The Plan denied your request. The Plan says you do not meet the criteria for admission to an IRF.  
 
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 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 pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively 
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to 
maintain your condition and/or prevent deterioration.  You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. As you do not have any skilled care needs, you 
do not meet medical necessity for home health aide services. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an overbed table. 
 
You asked the Plan to pre-approve an overbed table. You say that you can't eat because you don't have a table 
to put food on. You said that you are bed-bound and can't move or get up. The Plan denied your request. The 
Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that overbed tables are not covered because they are 
considered convenience items. While an overbed table 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 an 
overbed table.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 provided on the following dates of service: 
March 10, 2023, March 16, 2023, March 21, 2023, and March 26, 2023. 
 
You asked the Plan to pay for code 99233. You say that the medical records support the codes billed. The Plan 
denied your request. The Plan says code 99233 is not supported by the medical record. The medical records 
don't support a high level of medical decision making or the total time required of the code billed. The Plan has 
paid for code 99232 billed for the following dates of service: March 6, 2023, to March 9, 2023, March 11, 
2023, to March 15, 2023, March 17, 2023, to March 20, 2023, and March 22, 2023, to March 25, 2023. 
 
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 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 high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found this enrollee presented with osteomyelitis and pneumonia 
was treated with antibiotics. In this case, the documentation supports an appropriate exam, but not an 
appropriate history or medical decision making of high level. 
 
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 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 provided on the following dates of service: March 10, 2023, March 16, 2023, 
March 21, 2023, and March 26, 2023.