Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 27, 2022, to 
June 21, 2022. You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the NOA 
was not received timely. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 27, 2022. The NOA was not received by the Plan until July 27, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
May 27, 2022, to June 21, 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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The 
requested service cannot be 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral medial branch blocks (MBBs) (64493, 64494). 
 
You asked the Plan to pre-approve MBBs. You say that there was not enough time with the addendum. The 
Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary when certain 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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the provided documentation does 
not indicate the enrollee had at least 80% relief of primary pain. Therefore, the reviewer found that the 
requested MBBs are not medically reasonable or 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 MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve bilateral medial branch blocks (MBBs) (64493, 64494).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on January 20, 2023. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
without the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57772. 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 testing provided 
on January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0650) and a 
pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (E0675). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says pneumatic compression 
devices are not covered by Medicare for deep vein thrombosis (DVT) prevention. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0650) and a pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial 
insufficiency (E0675).
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 requires intensive rehabilitation to be 
able to return home. You also say the enrollee meets Medicare criteria for an IRF admission and you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says IRF care is 
not medically reasonable or 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 clinical documentation shows the enrollee has complex functional 
impairments but are now mostly resolved (now at supervision level, ambulating without assistive device). 
Thus, the complexity of the enrollee's documented nursing, medical, and rehabilitation needs would not be 
expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee requires ongoing skilled therapy, but inpatient goals have been. Therefore, the enrollee would not 
be expected to require an intensive rehabilitation regimen in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. You likely have chronic carbon dioxide (CO2) retention and may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has no daily skilled nurse or therapist needs. 
 
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 that the enrollee is functioning at a community level, and does not require daily 
skilled nursing or therapy to maintain function. The enrollee is independent in transfers, ambulating, or 
toileting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 13, 
2022. 
 You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty, right (27447). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the requested outpatient 
right total knee replacement 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for osteoarthritis of the knee and presented with right 
knee pain for over one year, with an acute exacerbation over the past three months. The enrollee's pain is rated 
at 4/10 at rest and 8/10 with ambulating more than a few blocks. However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. 
The enrollee is not clearly documented to have been through a formal course of physical therapy or a weight 
loss program. Additionally, the enrollee had a cortisone injection on January 30, 2023, without clear 
documentation of the results from that injection. 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. Therefore, the 
requested right total knee arthroplasty (CPT 27447), in this case, is not medically reasonable or 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty, right (27447).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (between hip and pelvis) joint fusion. 
 
You asked the Plan to pre-approve sacroiliac (between hip and pelvis) joint fusion. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that minimally invasive surgical fusion of the SI joint is 
covered for certain 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 sacroiliac (between hip and pelvis) joint 
fusion. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee was being treated for arthrodesis status, 
dorsopathies sacral and sacrococcygeal region, and intervertebral disc degeneration of the lumbar region. 
Conservative treatment included physical therapy and sacroiliac joint injections bilaterally. Conservative 
treatment included physical therapy and sacroiliac joint injections bilaterally.  detailed documentation is not 
evident regarding history of SI joint pain onset or failure of conservative treatment directed to the SI joint. 
Multiple other plausible pain generators including at the lumbosacral spine are evident. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac (between hip and pelvis) joint fusion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve sacroiliac (between hip and pelvis) joint fusion.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on April 6, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says that additional records are required to support these 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the requested documentation was submitted to the Plan since the 
initial denial. The Plan has not further clarified their denial nor provided any other reason why these services 
should not be paid. The Plan has not substantiated their denial in this case. Therefore, we decided that the Plan 
has to pay for laboratory services provided on April 6, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99236) provide on June 23, 2022. 
 
You asked the Plan to pay for inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed service. 
 
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 99236 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: Comprehensive history; Comprehensive exam and Medical decision making of high 
complexity. 
 
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 inpatient care. Our reviewer says that this service was not supported by the records provided. Our reviewer found the history documented was problem focused and not 
comprehensive. There is a more appropriate code for this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient care (99236) provide on June 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99222) provided on July 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this claim is 
inappropriately coded based on other claims received for this member. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that this claim is inappropriately coded based on other claims 
received for this member. However, the Plan has not provided a rationale as to why this claim is considered to 
be inappropriately coded, nor has the Plan provided documentation of the other claim they have received 
causing this claim to be deemed inappropriately coded. Without supporting documentation, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (99222) provided on 
July 11, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you are only allowed up to 60 one-way 
trips each year and additional trips will not be approved. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 58 of 
the 60 allotted trips for the 2023 benefit year. The Plan will not approve more than 60 one-way trips each year. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95955, 95908, 95927) provided 
on February 24, 2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed codes are 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. 
 
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 the neuromonitoring services. Our reviewer says that the 
records do not support the codes billed. Our reviewer found The procedures billed are not supported by the 
medical record as separately reportable diagnostic procedures. These services are included in the base 
interoperative neuromonitoring service. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the 
Plan does not have to pay for neuromonitoring services (95955, 95908, 95927) provided on February 24, 2021.