Persius/hicric huggingface dataset:
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 denial of SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 10, 2022, to 
October 28, 2022. 
 You asked the Plan to pay for the home health services. You say that these services were performed in the 
patient's home and this claim should be reprocessed. The Plan denied your request. The Plan says the NOA was 
not received timely. As such, this final claim was correctly denied.  
 
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 October 10, 2022. The NOA was not received by the Plan until January 7, 
2023. 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 home health services provided 
from October 10, 2022, to October 28, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for art therapy services provided by a Licensed Professional 
Counselor (LPC) from November 8, 2022, to December 30, 2022. 
 
You asked the Plan to pay for the LPC services. You say that these services should be reimbursed. The Plan 
denied your request. The Plan says these services are not covered because this provider is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
In this case, the services in dispute were provided by a LPC.  LPCs are not valid providers for Medicare, so 
these services cannot be covered.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LPC services have not been met. Therefore, we decided that the Plan does not have to pay for 
art therapy services provided by a Licensed Professional Counselor (LPC) from November 8, 2022, to 
December 30, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided October 23, 2022, to October 
25, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that observation care would have been more 
appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided October 23, 2022, to October 25, 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: 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 you 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 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 pneumonia. 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: 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 you 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 complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for lumbar spine surgery after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
You do 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 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 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 you feel that the services are medically necessary so 
you can return to being independent. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 9, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet coverage requirements. 
 
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 T12 kyphoplasty. Our reviewer says 
that the enrollee does not meet coverage criteria. Our physician reviewer found there is no documentation of a 
trial of 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 T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22899 billed for date of service October 28, 
2022. 
 
You asked the Plan to pay for procedure code 22899. You say that this service was medically necessary and 
was reported with the most accurate code. The Plan denied your request. The Plan says this code is not covered 
when it is provided in an ambulatory surgical center. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that there are certain services which are approved to be performed in an ambulatory surgical center under the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 22899 have not been met. Specifically, this code is not among those listed as 
approved for payment when provided in an ambulatory surgical center setting. These services were rendered in 
an ambulatory surgical center. Therefore, we decided that the Plan does not have to pay for procedure code 
22899 billed for date of service October 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 20, 2022, to 
October 17, 2022. 
 You asked the Plan to pay for the home health services. You say that you were not able to determine what data 
was missing or erroneous on this claim. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
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 September 20, 2022. The NOA was not received by the Plan until 
November 18, 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 home health 
services provided from September 20, 2022, to October 17, 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 you feel the service should be covered. You say you 
don't want to be in the hospital and would rather be in the IRF. The Plan denied your request. The Plan says 
you do not meet the guidelines 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 your 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 a minimally invasive lumbar decompression (MILD) 
procedure. 
 
You asked the Plan to pre-approve a MILD procedure. You say that the enrollee is participating in a clinical 
study and the requested service is a medical necessity. The Plan denied your request. The Plan says rules for 
coverage for a MILD procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when 
provided in a clinical study through CED for beneficiaries with LSS who are enrolled in an approved clinical 
study. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a MILD procedure have not been met. Specifically, the provided documentation does not support 
that the enrollee is participating in an approved clinical study. Therefore, we decided that the Plan does not 
have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and co-insurance of the chiropractic services 
rendered on October 19, 2020 to December 3, 2020.  
 
You asked the Plan to waive the deductible and co-insurance of the chiropractic services rendered on October 
19, 2020 to December 3, 2020. You say that these services were medically necessary. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is You have been asked to pay $11.81, which is 30% coinsurance of the 
allowed amount for the chiropractic services provided from October 29, 2020, to November 12, 2020, and from 
November 19, 2020, to December 3, 2020 ($39.37 allowed amount x 30% coinsurance = $11.81). You have 
also been asked to pay $21.41, which is 30% coinsurance of the allowed amount for the chiropractic services provided on November 16, 2020 ($71.39 allowed amount x 30% coinsurance = $21.41). which applies to 
Chiropractic services.  
 
The item or service you asked the Plan to waive the deductible and co-insurance of the chiropractic services 
rendered on October 19, 2020 to December 3, 2020 falls within the Chiropractic services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is You have been asked to pay 
$11.81, which is 30% coinsurance of the allowed amount for the chiropractic services provided from October 
29, 2020, to November 12, 2020, and from November 19, 2020, to December 3, 2020 ($39.37 allowed amount 
x 30% coinsurance = $11.81). You have also been asked to pay $21.41, which is 30% coinsurance of the 
allowed amount for the chiropractic services provided on November 16, 2020 ($71.39 allowed amount x 30% 
coinsurance = $21.41). which applies to Chiropractic services. This cost sharing is a contractual obligation that 
had not been met at the time chiropractic services was received on October 19, 2020 to December 3, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible and co-insurance of the chiropractic 
services rendered on October 19, 2020 to December 3, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve ablation of malignant prostate tissue transrectal with high 
intensity-focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the health plan has no contractual obligation to cover services that are not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor 
investigational. HIFU was FDA approved for prostate gland ablation October 9, 2015. HIFU of the prostate 
(procedure code 55880) has Medicare coverage as of July 1, 2017. More than 100 clinical studies have 
demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side 
effects such as impotence, urinary incontinence and bowel injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve ablation of malignant prostate tissue transrectal with high intensity-focused ultrasound (HIFU).  
 
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.