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

 
We decided that the Plan does not have to pre-approve 3 genicular nerve blocks. 
 
You asked the Plan to pre-approve the nerve blocks. You say that the requested blocks are medically necessary 
to relieve your knee pain.  The Plan denied your request. The Plan says the requested nerve blocks are 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 nerve blocks. Our reviewer says that 
the requested genicular nerve blocks are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this therapy is the subject of ongoing clinical trials to determine it's role in the 
management of knee pain.  It is considered experimental at this time.  Therefore, the requested nerve blocks are 
not medically reasonable and necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 3 genicular nerve blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment purchased on January 10, 2023. 
 
You asked the Plan to pay for oxygen equipment. You say that you needed to purchase this item. The Plan 
denied your request. The Plan says this was purchased outside of the United States from a provider that does 
not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for oxygen equipment purchased on January 
10, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 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 
was admitted for altered mental status. 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 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95819 billed for date of service August 11, 
2022. 
 
You asked the Plan to pay for procedure code(s) 95819. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says this code is billed without the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
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 records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95819. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 95819. Based on this information, 
we decided that Medicare rules for coverage of procedure code 95819 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 95819 billed for date of service August 11, 
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 it is medically necessary. The Plan 
denied your request. The Plan says you do not meet the requirements for approval. 
 
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 you are a 67-year-old for whom admission to a long-term acute care hospital 
(LTACH) has been requested. At issue is whether LTACH services are medically necessary, reasonable, and 
appropriate for your diagnosis and condition. You were admitted to the acute care hospital on May 13, 2023, with sepsis. You developed complications with 
septic shock, and required biliary stent placement, cholangiogram, and a biliary drain exchange. You are 
receiving IV antibiotics for Klebsiella bacteremia. On May 31, 2023, you were "Still doing well. The 
Occupational Therapy Anticipated Discharge Disposition was for an inpatient setting with 3 or more hours of 
skilled therapy per day. 
 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short-term acute care hospitals. You are 
receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that you in this case requires services at the LTACH that are not available at the acute care hospital 
where you are currently receiving care. There are no required medical services identified that are available at 
the LTACH, that are not available at the current health care setting being offered by the health plan. 
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee at this time.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report testing provided on 
October 27, 2022, and billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 
81335, and 81328.  
 
You asked the Plan to pay for the GeneDose Genetic Response Report testing . You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this test should be billed with a single panel 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the GeneDose Genetic Response Report testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneDose Genetic 
Response Report testing provided on October 27, 2022, and billed with codes 81225, 81226, 81227, 81231, 
81232, 81240, 81241, 81291, 81306, 81335, and 81328.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601), provided on August 8, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a claim for an E0601 is submitted and all of the 
coverage criteria have not been met, it will be denied as not reasonable and necessary. 
 
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 CPAP device. Our reviewer says that 
you do not need this medical item. Our physician reviewer found the provided records do not document an 
apnea hypopnea index or respiratory disturbance index greater than or equal to 15 events per hour, or greater 
than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive 
daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic 
heart disease, or history of stroke. They also do not document a clinical re-evaluation and documentation that 
the patient is benefiting from the CPAP therapy. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to pay for the continuous positive airway pressure (CPAP) device (E0601), provided on August 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on September 24, 
2022. 
 
You asked the Plan to pay for initial hospital care (99223). The Plan denied your request. The Plan says the 
medical records submitted do not support a comprehensive history. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
  In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 initial hospital care (99223). Our reviewer says that 
procedure code 99223 is not supported in the medical records. Our reviewer found that the enrollee admitted 
after a ground level fall which resulted in a right hip fracture, but no comprehensive history was obtained. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) provided on September 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve an injection. You say that the request is medically necessary due to the 
enrollee suffers from midline back pain for five years. The Plan denied your request. The Plan says the request 
is not medically necessary because there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for the enrollee's back pain. 
 
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 an injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the enrollee has chronic low back pain. The enrollee has had failure of conservative treatment 
including NSAIDS, analgesics, steroids, physical therapy, epidural steroid injections, structured or prescribed 
home exercise program. Radiographic finding demonstrates early to moderate disc degeneration at L3-L4, L5 
AND L5-S1 and annual fissures at L2-L3 and L3-L4. She had Via Disc NP injected and did not have 
significant pain relief. This is experimental/ investigational therapy. Therefore, the request is deemed not 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral 
disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 21, 2022, 
to May 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that your organization made every 
effort to submit the NOA timely and accurately. The Plan denied your request. The Plan says the claim has not 
been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 21, 2022, to 
May 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirement 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 is a 48 -year-old appealing the denial of an IRF admission. Record 
reviewed. The enrollee was admitted to an acute hospital on May 17, 2023, with chest pain, hematuria, UTI, 
and recurrent Colitis Treated with improvement. Medically stable with debility. PMH: Morbid obesity, Crohn's 
disease, Lupus, RA, Depression, HTN, HLD, DM, CKD, COPD, OSA, DVT, left thumb fracture after a fall, 
ETOH abuse, Hepatitis Band urinary retention with a Foley in place. Referred to an IRF for admission on May 
22, 2023, with an ELOS of 14 days. PLOF: Wheelchair bound requiring min A for ADLs. Therapy notes 
reviewed. Required SBA for bed mobility and transfers on May 30, 2023 with decreased activity tolerance. 
Noted not making progress as expected by physical therapy. Min to mod A for ADLs. 
 
On review of the available records, the enrollee with history as described above does not meet CMS coverage 
criteria for IRF admission. The enrollee is medically stable despite multiple chronic comorbidities and does not 
need PMR physician's supervision 3 times a week in an IRF. No medical complexity. No acute rehab nursing 
needs identified or documented. At the current functional level, the enrollee does not need specialized and 
intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. Document does not support necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehab, and medical, needs (combined complexity) does not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. While the enrollee 
may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be provided in a 
lower intensity and alternate setting such as in an SNF.  
 
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 a transforaminal epidural steroid injection. 
 You asked the Plan to pre-approve epidural steroid injection. You say that this is needed to improve pain and 
provide more daily functional living. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections are only covered under 
certain criteria. 
 
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 epidural steroid injection. Our reviewer 
says that the enrollee meets the Medicare criteria for this epidural. Our physician reviewer found there is no 
foraminal or central spinal stenosis confirmed on the most updated imaging to the L3-L4 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transforaminal epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulpal debridement services (D3221) provided on December 
1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pulpal 
debridement services (D3221) provided on December 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 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 
was admitted for atrial fibrillation and lower extremity deep vein thrombosis and was discharged to skilled 
nursing on May 9, 2023. 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 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.