Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection panel provided on March 8, 2022. 
 
You asked the Plan to pay for the testing. 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that diagnosing fungal nail infection is typically based on examination only and doesn't typically require confirmation testing. If testing is warranted based on atypical clinical presentation, which was not the case 
here, culture or potassium hydroxide (KOH) testing is the standard of care. The polymerase chain reaction 
(PCR) testing was excessive in this case, and it was not explained in the documentation how it would lead to an 
improved outcome over standard testing and diagnosing methods. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the fungal infection panel provided on March 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service January 2, 
2023. 
 You asked the Plan to pay for procedure code 71045-26. You say that you do not believe this code should be 
bundled. The Plan denied your request. The Plan says payment for code 71045-26 is bundled into payment for 
code 32555-LT. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
71045-26 is a column II code to column I code 32555-LT. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service 
January 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left hip endoscopic trochanteric bursectomy with 
abductor repair (29863, 27027, 29999). 
 
You asked the Plan to pre-approve left hip endoscopic trochanteric bursectomy with abductor repair. You say 
that this is medically necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the left hip endoscopic trochanteric bursectomy with abductor repair in the setting of 
trochanteric bursitis/hip pain have not been demonstrated in the peer-reviewed literature. 
 
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 left hip endoscopic trochanteric 
bursectomy with abductor repair. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is 
not evident. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left hip endoscopic trochanteric bursectomy with abductor repair have not been 
met. Therefore, we decided that the Plan does not have to pre-approve left hip endoscopic trochanteric 
bursectomy with abductor repair (29863, 27027, 29999).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted spine procedure (22899 x 2) provided on 
October 10, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the billed code is an unlisted code which is 
submitted for the special features of the anterior retroperitoneal approach to the spine. You also say that this should be reprocessed and paid. The Plan denied your request. The Plan says the description given does not 
meet the criteria for payment of unlisted codes. 
 
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 22899 is unlisted procedure, spine. 
 
We asked our physician 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 surgical services. Our reviewer says that the 
documentation does not support the billed service. Our reviewer found the provided medical records document 
in detail the specifics of procedure code 22899; however the provider did not submit the detailed explanation of 
procedure code 22899 with a corrected claim to the Health Plan. Therefore, the reviewer found that the billed 
procedure code, 22899, is not eligible for reimbursement consideration. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted spine procedure (22899 x 2) provided on October 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the level of care needed. The Plan denied your request. The Plan says the enrollee's 
medical needs are being met in the current facility.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical studies haven't proven this service/item is helpful for treatment of 
the enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging shows facet degenerative joint disease and 
spondylolisthesis. The cause of back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services and anesthesia services provided in a 
hospital setting on November 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you never signed an advanced beneficiary 
notice of noncoverage (ABN) form. You also say that you feel you should not be responsible for this bill. The 
Plan denied your request. The Plan says the services in this case are dental in nature. The Plan says that the 
services are not eligible for coverage under your medical benefit. The Plan also says that the comprehensive 
dental benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital inpatient services, which are necessary 
because of the patient's underlying medical condition and clinical status or the severity of a noncovered dental 
procedure, may be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the dental services have not been met. Additionally, the file supports that the annual maximum 
benefit for dental services was exhausted prior to the date of service in this case. Therefore, we decided that the 
Plan does not have to pay for the dental services and anesthesia services provided in a hospital setting on 
November 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health services visits 
 You asked the Plan to pre-approve home health services. You say that the home health services is medically 
necessary for the enrollee. 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 that the 
enrollee does not have documented skilled therapy needs. The enrollee is ambulating independently. Ongoing 
home health physical therapy services are not shown to be medically necessary or reasonable. 
 
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 9 home health services visits
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 to be admitted to an IRF due to 
being a high fall risk and not being able to stand or walk on their own. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare 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 the enrollee's 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office consultation. You say that the requested provider has been your 
doctor for years. The Plan denied your request. The Plan says rules for coverage for OON services have not 
been met. 
 
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 
an office consultation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs procedure. 
 
You asked the Plan to pre-approve Mohs procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. 
 
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 Mohs procedure. Our reviewer says that 
you do not meet coverage criteria. Our physician reviewer found based on the community standard of care of 
such tumor lesions you do not meet criteria for coverage. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mohs procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Mohs procedure.
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 you to 
regain stability. The Plan denied your request. The Plan says ongoing skilled care can be provided in an 
alternative 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 that 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet all for the requirements for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria 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 L2 kyphoplasty. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is no documentation of a trial of 
fracture bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve omeprazole. 
 
You asked the Plan to pre-approve omeprazole. You say that the enrollee would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that self-administered drugs do not fall 
under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve omeprazole.  
 
Benefits for omeprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 requesting an expedited appeal for the denial 
of an IRF admission based on medical necessity. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 wants to go to an IRF and not a skilled 
nursing facility. You say the enrollee is strong enough to complete the therapy involved with inpatient 
rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  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. 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 that 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.