Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 25600. We decided that the Plan does not have to pay for code 
99285.  
 
You asked the Plan to pay for procedure codes 25600, & 99285 provided on June 30, 2023. You say that these 
services were medically necessary. The Plan says that coverage criteria has not been met. 
 
We decided that the Plan has to pay for code 25600.  
 
The Plan follows Medicare rules. Medicare rules say that the rules say that providers/suppliers must report 
services correctly. 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 service at issue. Our reviewer says that 
code 25600 is supported. Our physician reviewer found the records support a Closed treatment of distal radial 
fracture. Records show splinting was performed and the patient was referred to orthopedics. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for code 25600.  
 
We also decided that the Plan does not have to pay for code 99285. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare rules say that the rules say that 
providers/suppliers must report services correctly. 
 
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 service at issue. Our reviewer says that 
the records do not support code 99285. Our physician reviewer found an emergency department visit for the 
evaluation and management of a patient requiring a medically appropriate history, and/or examination, and 
high level of medical decision making is not supported in the records. The records do not show medical 
decision making of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service at issue have not been met. Therefore, we decided that the Plan does 
not have to pay for code 99285. 
 
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 pre-approve Barostim Neo System (C1825, 0266T). 
 
You asked the Plan to pre-approve Barostim Neo System. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Barostim Neo System. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim Neo System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Barostim Neo System (C1825, 0266T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA) services 
(64624).  
 
You asked the Plan to pre-approve genicular RFA services. You say that the enrollee underwent a left knee 
diagnostic genicular nerve block which provided 95% pain relief. You say that the most appropriate course 
would be a radiofrequency ablation of the left knee to provide a more long-lasting pain relief for the enrollee. 
The Plan denied your request. The Plan says this is experimental for the enrollee's condition. 
 
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 genicular RFA services. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy. It is the subject of ongoing clinical trials.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular RFA services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular radiofrequency ablation (RFA) services (64624).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
imaging (78452). 
 
You asked the Plan to pre-approve SPECT imaging services. You say that the records provided support the 
need for the imaging in dispute. The Plan denied your request. The Plan says the requested imaging 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 SPECT imaging services. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical appropriateness and necessity of carrying out a radionuclide stress test, 
rather than a treadmill stress test is what is at issue.  There is no documentation that the electrocardiogram 
(ECG) shows an uninterpretable pattern. There is no evidence provided that would support the need for 
radionuclide stress testing. There is insufficient documentation to support the medical necessity for the 
requested cardiac stress testing in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT imaging services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve single photon emission computed tomography (SPECT) imaging (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 24, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on January 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the Barostim Neo system would not be considered medically reasonable and 
necessary in your clinical management. 
 
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 Barostim Neo device. Our reviewer 
says that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. Our physician reviewer found at this 
time, the Barostim Neo system would not be considered medically appropriate and necessary in your clinical 
management.  
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 Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device (0266T, C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 31, 2023, billed with 
procedure code 29581-RT-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the requested medical records have not been 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, medical records for the date of service in question have not been provided for review. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on May 31, 2023, 
billed with procedure code 29581-RT-59.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing visits. You asked the Plan to 
pre-approve home health services. You say that you are appealing due to medical necessity. The Plan denied 
your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found enrollee does 
not have documented skilled nursing needs. As such, the requested skilled nursing services are not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services as the intensive level 
of therapy and training needed cannot be provided at a lower level of care. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for an IRF admission.  
 
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 
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. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 radiofrequency ablation, nerves 
innervating the sacroiliac joint, with image guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found this is 
considered experimental/ investigational therapy because of the wide variation in efficacy reported in the peer 
reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency 
ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's condition does not meet all the 
requirements 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 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's 
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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (U0003, U0005, G2023) provided on 
March 2, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that multiple claims have denied for being 
bundle when they have been sent correctly. The Plan denied your request. The Plan says this code is included 
in the skilled nursing facility payment and is 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 CPT code.  
The records indicate that this service was provided to the enrollee while a skilled nursing facility (SNF) 
inpatient. All services billed by the SNF (including those furnished under arrangements with an outside 
supplier) for a resident of a SNF in a covered Part A stay are included in the SNF's Part A bill. Payment to you 
for this service is the responsibility of the SNF. 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 laboratory services (U0003, U0005, G2023) provided on March 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not provide a face-to-face provider order for home health services. The records do not 
show that home health skilled nursing is required to effectively provide treatment, care, and/or services in order 
to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) system. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried conventional 
treatment without sustained pain relief. The Plan denied your request. The Plan says the system does not meet 
criteria for an implanted neurostimulator, and it has not been shown to be effective in medical literature.  
 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 requested services. Our physician 
reviewer found that the enrollee has chronic right knee pain. She has had medication trials, physical therapy, 
heat and ice, steroid injections and nerve blocks. The request is considered an experimental procedure. It is the 
subject of ongoing clinical trials. 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this care to regain 
mobility. The Plan denied your request. The Plan says the enrollee's needs can be managed at the current 
facility until they are more stable for transfer to another level of care. 
 
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 already available at 
the current facility.  
 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.