Persius/hicric huggingface dataset:
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 has a medical need for IRF services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the services are medically necessary, and you 
have been trying to get these services approved for the enrollee for over a month. The Plan denied your request. 
The Plan says there is insufficient information to approve the request. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had extensive prior physical therapy. The enrollee has 
had instruction in a home exercise program. The enrollee can transition to an independent home exercise 
program and does not require ongoing supervised skilled physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 11 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the enteral feeding supply kit on August 
25, 2022, to July 26, 2023.  
 
You asked the Plan to waive the coinsurance for the enteral feeding supply kit. You say that you feel that you 
are being overcharged and think that when the claims get adjusted you keep having to owe more money. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for prosthetic devices and related supplies.  You have been asked to pay a 20% coinsurance for each enteral feeding supply kit. This item/service falls 
within the prosthetic devices and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The total amount you owe is $302.43, which is 20% coinsurance 
of the allowed amount for each item. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the enteral feeding supply kit on August 25, 2022, to July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that you are appealing the denial. The 
Plan denied your request. The Plan says that the request does not meet medical necessity requirements. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found while the enrollee has a history of atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent 
indication for an ILR. 
 
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 ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that it is paramount to perform the 
injection as the enrollee's pain is worsening and affects her quality of life. The enrollee has tried and failed 
many conservative methods of pain management. The Plan denied your request. The Plan says the service is 
not medically necessary until efficacy of this procedure has been established. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has left knee osteoarthritis and fibromyalgia. The requested injection is 
considered experimental therapy for knee pain. It is the subject of ongoing clinical trials. Therefore, the request 
is deemed 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches (64454).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH services.  
The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of the 
requested LTACH services. 
 
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. Given there are offered alternatives, LTACH 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 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: 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 SNF care is medically necessary. The Plan denied 
your request. The Plan says the criteria for SNF care has not been met. 
 
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 you are improving, requiring minimal assistance with mobility and self-care tasks. 
The documentation does not support the need for daily skilled services on an inpatient basis in a skilled nursing 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology evoked potentials (NEPs) testing (95938 
and 95939) provided on February 13, 2023. 
 
You asked the Plan to pay for NEPs testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says these services were not billed with a covered diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that NEPs test codes 95938 and 95939 are not 
supported for coverage when billed with diagnosis code G95.9.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of NEPs testing have not been met. Therefore, we decided that the Plan does not have to pay for 
neurophysiology evoked potentials (NEPs) testing (95938 and 95939) provided on February 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve romosozumab-aqqg injection, 1 mg (J3111). 
 
You asked the Plan to pre-approve the medication. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this service is not medically 
necessary and does not alight with FDA guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the Evenity was denied per the Plan policy as Evenity is covered for 
the treatment of osteoporosis in women who are postmenopausal and is not approved by the FDA for treatment 
in men. In addition, the provider did not submit bone mineral density test results confirming the suspected 
diagnosis of osteoporosis. The review has determined that the documentation did not support that the Injection, 
romosozumab-aqqg, is medically reasonable and necessary for the enrollee. The documentation does not 
support that the Injection, romosozumab-aqqg, is safe and effective for the enrollee. 
 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve romosozumab-aqqg injection, 1 mg (J3111).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64491 billed for date of service June 9, 2023.  
 
You asked the Plan to pay for procedure code 64491. 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 64491 is 1 The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64491 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64491 billed for date of service June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99214-25 
billed on date of service April 21, 2023. 
 
You asked the Plan to pay for 99214-25. You say that 99214-25 should be paid as billed because it is supported 
in the documentation. The Plan denied your request. The Plan says payment for 99214-25 is denied because it 
is included in the payment for the minor procedure performed on the same date of 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. The rules also say in general, evaluation and 
management services on the same date of service as a minor surgical procedure are included in the payment for 
the procedure. A significant and separately identifiable evaluation and management service unrelated to the 
decision to perform the minor surgical procedure is separately reportable with modifier -25. 
 
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 99214-25. Our reviewer says that 99214-25 is not supported. 
Our reviewer found the record does not support that separately identifiable evaluation and management 
services that were not related to the procedure described by code 17250 were performed during this encounter. 
The only evaluation and management services in this case are related to and included in the procedure and 
should not be reported separately with modifier -25. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99214-25 have not been met. Therefore, we decided that the Plan does not have 
to pay for the evaluation and management services coded as 99214-25 billed on date of service April 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS) therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the current peer-reviewed medical 
literature does not document that use of the Sprint PNS device has been shown in controlled studies in a 
Medicare-approved journal to result in sustained long term health benefits in patients with chronic low back 
pain. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint peripheral nerve stimulator (PNS) therapy.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a high-intensity focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve an HIFU. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 an HIFU. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found HIFU is medically reasonable and necessary in this case. HIFU treatment of the prostate is 
neither experimental nor investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an HIFU have been met. Therefore, we decided that the Plan has to pre-approve 
a 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479). 
 You asked the Plan to pre-approve genetic testing. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested test is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that NGS is reasonable and necessary and covered 
nationally when all of the requirements listed in the Medicare rules section of this letter are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the requested test is an NGS myeloid neoplasm 
panel. Medicare records do not support that this test is approved and eligible for coverage. Therefore, we 
decided that the Plan does not have to pre-approve genetic testing (81479).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you disagree with the denial. 
The Plan denied your request. The Plan says you have exceeded your benefit limit for the year. 
 
 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 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of inpatient care provided from March 27, 2023, 
to March 31, 2023. 
 
You asked the Plan to pay for continuation of inpatient care. You say that continuation of inpatient care was 
medically necessary. The Plan denied your request. The Plan says continuation of inpatient care was 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 pay for continuation of inpatient care. Our reviewer says that continuation of inpatient care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that ongoing inpatient care was not medically necessary after March 26, 2023. The 
enrollee was transitioned to Hospice and awaiting placement. There was no expectation that inpatient level 
services would be provided. Time spent waiting for placement does not meet the definition of 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 continuation of inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of inpatient care provided from March 27, 2023, to March 31, 2023.