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

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of a SNF admission. The Plan denied your request. The Plan says the enrollee does not meet medical 
necessity criteria for a SNF level of care. 
 
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. The enrollee is ambulatory and able to tend to activities of daily living with minimal 
supervision. The enrollees care needs can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested compression 
stockings are medically necessary. The Plan denied your request. The Plan says the requested item is a not 
covered by the Plan or Medicare. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you have not trialed one of the preferred 
viscosupplemental treatments such as, Monovisc, Orthovisc, Synvisc or Synvisc One. Step therapy, as outlined 
by the Plan, requires that one of these be trialed first. The documentation does not outline contraindications or 
reasons these medications were not considered or that the plans additional required drug would likely be less 
effective and/or likely have adverse effects for you. Without the support of the documentation, Euflexxa is not 
approved as step criteria 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary as 
the enrollee requires vent weaning that will take time. The Plan denied your request. The Plan says the enrollee 
is receiving appropriate inpatient acute care and is currently unstable for 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care it is medically necessary so that the enrollee 
can regain their complete function and independence. The Plan denied your request. The Plan says the records 
do not show that the enrollee needs to be seen by a rehabilitation doctor or that they require intensive services 
consisting of 3 hours of daily therapies for their rehabilitation. 
 
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 was admitted to the hospital on April 27, 2023, for diabetic ketoacidosis, hypernatremia, and metabolic 
encephalopathy. The enrollee has not had a significant change in his baseline medical conditions and their 
metabolic encephalopathy has nearly resolved. The enrollee has not had an acute change in their neurological 
condition and imaging of the brain was unremarkable. The enrollee does not require rehabilitation nursing for 
complex wound care, parenteral nutrition or tube feedings, tracheostomy management or neurogenic bowel and 
bladder management. The enrollee's medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, or 15 hours 
over 7 consecutive days. Physical therapy documentation dated May 5, 2023, indicated that the enrollee 
required contact guard assistance for bed mobility and minimal assistance for transfers and ambulating with a 
single point cane. Occupational therapy documentation dated May 8, 2023, indicated that the enrollee required 
minimal assistance for daily activities. The enrollee has had a decline from his baseline level of function and 
would likely benefit from therapy and/or assistance, but they do not require the intensity of therapies provided 
on acute inpatient rehabilitation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the natriuretic peptide testing (83880) provided on 
November 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not 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 pay for the laboratory services. Our physician 
reviewer found there was no specific indication for a BNP test. The review has determined that the requested 
testing was not medically reasonable and necessary according to the coverage indications established in the 
LCD. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the natriuretic peptide testing (83880) provided on November 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided from October 20, 2022, to 
October 21, 2022. 
 
You asked the Plan to pay for outpatient services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says there is an I/OCE error on this claim which 
means this claim must be returned for correction and cannot be paid at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that Edit 8 is invoked when the 
sex of the patient does not match the sex designated for the procedure code reported. This edit is bypassed if 
condition code 45 is present on the claim. The disposition for this edit is "return to provider" (RTP), which 
means that there is one or more edits present which cause the entire claim to be denied and returned to the 
provider. A claim returned to the provider means that the provider can resubmit the claim once the problems 
are corrected. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, the records indicate that the enrollee in this 
case is female, but the claim in question includes procedure code 84153 (prostate specific antigen assay), which 
is a male-only procedure. This claim does not include condition code 45. This means that Edit 8 is invoked in 
this case, and the entire claim is returned to the provider for correction and no payment can be made at this 
time. Therefore, we decided that the Plan does not have to pay for outpatient services provided from October 
20, 2022, to October 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22845, & 20930 billed for date of service 
July 13, 2022. 
 
You asked the Plan to pay for procedure codes 22845, & 20930. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the codes billed are 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 20930 has a status indicator of B on the Physician Fee Schedule. Code 22845 has 
a bundled relationship with code 22853 which was also billed. This means that procedure codes 22845, & 
20930 are not separately payable. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 22845, & 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 22845, & 20930 billed for date of service July 13, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided November 24, 2022, to 
November 30, 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 the medical criteria for an inpatient admission have 
not been met. 
 
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 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 November 24, 2022, to November 30, 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 pay for the acute inpatient hospital care provided May 14, 2022, 
through May 19, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary for the enrollee. The Plan denied your request. The Plan says an inpatient admission was not 
medically necessary for the enrollee. 
 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 emergency department (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 does not have to pay for the acute inpatient hospital care provided May 14, 2022, through May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable with the billed diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that thyroid testing is only covered for certain 
diagnosis codes.  
 
We looked at the file and Medicare rules. Per NCD 190.22, diagnosis codes Z51.12, C34.12, R06.02, Z87.891, 
and C34.92, are not covered for the billed thyroid testing. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab services provided on November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-check guide test strips. 
 
You asked the Plan to pre-approve Accu-check guide test strips. You say that the items are necessary. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Accu-check guide test strips. Therefore, we decided that the Plan does not have to pre-approve Accu-check 
guide test strips.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says a SNF admission is not medically necessary, and the enrollee's needs can be met in 
another setting. 
 
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 require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this service is helpful for treatment. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the magnetic resonance imaging (MRI) shows disc herniation, facet degenerative joint 
disease, and stenosis. Therefore, the cause of the back pain is unclear, and this request is not medically 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contrast injection(s) for radiologic evaluation of existing 
central venous access device, including fluoroscopy, image documentation and report rendered on October 18, 
2022. 
 
You asked the Plan to pay for the services. You say that this code is payable as billed. The Plan denied your 
request. The Plan says the anatomical modifier is missing. 
 
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 find that CPT code 36598 is not supported in the medical record. Specifically, an anatomical modifier was 
not reported with this code. This is required for this code. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for contrast injection(s) for radiologic evaluation of existing central venous access device, including 
fluoroscopy, image documentation and report rendered on October 18, 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 the services are necessary as you have nowhere to go 
to receive the care needed. The Plan denied your request. The Plan says your needs can be met in an alternate 
level of care. 
 
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.