Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you say you need LTACH services and 
that you do not want to go to a nursing home. The Plan denied your request. The Plan says admission to the 
LTACH is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating the medical necessity for 
admission to an LTACH. You are receiving appropriate care at the present acute care hospital. There are no 
services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your 
diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee with benefit from acute rehabilitation to 
optimize level of functioning prior to returning home. The Plan denied your request. The Plan says the IRF 
services requested 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the test is needed to identify either AD or FTD 
as well as to guide treatment. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee was not noted to have either 
AD or FTD, let alone both. The base requirement of the NCD for coverage of the requested service has not 
been met. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV). 
 
You asked the Plan to pre-approve a POV. You say that you cannot walk more than 30 feet. You also say that 
with the scooter, you are able to get around and do grocery shopping. The Plan denied your request. The Plan 
says there is no evidence that a POV is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 a POV. Our reviewer says that a POV is 
not medically reasonable and necessary for you. Our physician reviewer found you function independently in 
the home. Our reviewer also found that you do not require a power mobility device to manage your mobility 
assisted activities of daily living in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
October 2, 2022, billed with code 99285. 
 
You asked the Plan to pay for the ED services. You say that these services were correctly coded.  The Plan 
denied your request. The Plan says code 99285 is not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 ED services. Our reviewer says that the 
code billed is not supported by the records. Our reviewer found the enrollee presented to the ED with a history 
of 24 hours of right-sided pleuritic chest pain. She was evaluated with a history and physical and discharged 
home with a diagnosis of pleurisy. The review indicates that code 99285 was not supported in the medical 
records. Specifically, there was no medical decision making of high complexity. 
 
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 ED services have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department (ED) services provided on October 2, 2022, billed with code 99285.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction (eg, laser surgery, electrosurgery, 
cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 
14 lesions, each (17003) provided on November 11, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the file shows that procedure code 17003 was billed with 19 units for date of service November 11, 
2022. Per CMS MUE guidelines, code 17003 has an MUE value of 13, and an MAI indicator or 2. This means 
that the provider may only bill 13 units of 17003 per day. As the provider exceeded that limit, we find that the 
Medicare rule for payment of this claim has not been met. 
 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. 
Therefore, we decided that the Plan does not have to pay for the destruction (eg, laser surgery, electrosurgery, 
cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 
14 lesions, each (17003) provided on November 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
October 19, 2022. 
 You asked the Plan to pay for procedure codes 87481 and 87653. The Plan denied your request. The Plan says 
payment for codes 87481 and 87653 is bundled into payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for 
date of service October 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96374 billed for date of service November 7, 
2022. 
 You asked the Plan to pay for procedure code 96374. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 96374 is bundled into payment for code 38505. 
 
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 96374 
is a column II code to column I code 38505. 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 96374 billed for date of service November 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0953, E0955, E2601, E2620, E1007, 
E1012, E2361, E1028, E2311, E2313, E2377, and K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that a power chair would drastically improve your quality of life. 
You also say that you need a power chair to be able to move around in and outside of your home. The Plan 
denied your request. The Plan says you do not have medical need for multiple power options available with 
K0861 group 3 power wheelchair. The Plan also says an expandable controller, harness, and electronics are not 
medically needed, and the controller shroud (K0108) does not serve a medical purpose. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (MRADLs), the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the 
patient is not capable of safely operating the requested PMD. 
 
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 a group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that you do not meet the 
coverage criteria. Our physician reviewer found you are not at high risk for skin breakdown, do not use 
intermittent catheterization, or have spasticity requiring special positioning. Our reviewer also found that you 
have adequate strength to manage standard controls. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E0953, E0955, E2601, E2620, E1007, E1012, E2361, E1028, E2311, E2313, E2377, and 
K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs justify an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 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. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.  
 
You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that a lumbar epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the requested lumbar epidural 
steroid injection is not medically necessary.  
 
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 a lumbar epidural steroid injection. Our 
reviewer says that the requested lumbar epidural steroid injection is not considered medically necessary in this 
case. Our physician reviewer found that the medical records do not show that the enrollee has disc herniation, 
osteophyte or osteophyte complexes, severe degenerative disc disease, post-laminectomy syndrome or acute 
herpes zoster. The review has determined that the requested lumbar epidural steroid injection does not meet the 
Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar epidural steroid injection.
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 enrollee is medically stable and will 
benefit from a transfer to an LTACH. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to an LTACH. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says admission to the IRF 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 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 do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (6428 64629). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you believe the denial of the Intracept 
procedure is unwarranted and unsupported by the enrollee's current medical status and current peer-reviewed 
literature. The Plan denied your request. The Plan says this procedure is considered experimental and 
investigational and therefore 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 looked at the file, and Medicare rules. Radiofrequency ablation of the basivertebral nerve is considered 
experimental and investigational and therefore not medically necessary. There is insufficient evidence to 
determine that radiofrequency ablation of the basivertebral nerve improves health outcomes. 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 (6428 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ProstateNow test. 
 
You asked the Plan to pre-approve the ProstateNow test. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved. 
 
We looked at the file and Medicare rules. Research show that the ProstateNow test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the ProstateNow test have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the ProstateNow test.