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

 
We decided that the Plan does not have to pre-approve an Inspire device. 
 You asked the Plan to pre-approve an Inspire device. 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 follows Medicare rules. Medicare rules say that FDA-approved hypoglossal nerve neurostimulation is 
considered medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea 
when certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Inspire device. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found implantation of a hypoglossal 
nerve stimulator (Inspire device) is considered not medically necessary.  You have obstructive sleep apnea and 
are intolerant of continuous positive airway pressure (CPAP). The physician's note from January 10, 2023 
indicates an apnea-hypopnea index (AHI) of 28, but the sleep study report is not provided. Your body mass 
index (BMI) is 36.9; Medicare criteria include a BMI less than 35. There is no indication in the record that 
sleep endoscopy has been performed to document absence of concentric airway collapse. 
 
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 Inspire device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Inspire device.
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 enrollee is a fall risk, and the rehab is medically 
necessary. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the 
requirements for approval. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99349 provide November 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not billable 
with place of service 32. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 99341 - 99350 will be used to report E/M 
services furnished to a patient residing in their home, in an assisted living facility, in a group home (that is not 
licensed as an intermediate care facility for individuals with intellectual disabilities), in a custodial care facility, 
or in a residential substance abuse treatment facility. 
 
We looked at the file and Medicare rules. The claim in this case was billed with place of service (POS) 32. Per Medicare rules, code 99349 is not billable with a nursing facility place of service (32). 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 services (99349 provide November 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen testing by nucleic acid provided on 
November 29, 2022.  
 
You asked the Plan to pay for the nucleic acid testing. You say that this was medically necessary and should be 
reimbursed.  The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the nucleic acid 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
pathogen testing by nucleic acid provided on November 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 11, 2022 to 
March 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 11, 2022 to 
March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic obstructive pulmonary disease (COPD) and has had a home ventilator since at least 2019. There are also 
diagnoses of heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation. The records do not 
include documentation of chronic carbon dioxide (CO2) retention with an arterial blood gas (ABG) done while 
stable. The records do not document a trial and failure of a bi-level positive airway pressure (BiPAP) device. 
The home ventilator is therefore not reasonable or medically necessary at this time. 
 
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 a home ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 30, 2022, to 
May 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted, and this 
claim should be paid. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that subsequent claims must report the date from the NOA as 
the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA. Based on this information, we find that the Medicare rules for payment 
of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from April 30, 2022, to May 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and each 
additional facet joint (64636). 
 
You asked the Plan to pre-approve the services. You say that you have tried epidurals in the past, the burning 
of the nerves is what works for you. You state that you are in a great amount of pain and the procedure 
generally lasts 6 or 7 months at most. The Plan denied your request. The Plan says the Medicare rules have not 
been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the review has determined that the requested procedures are not medically necessary as you have had 
medial branch blocks (MBBs) done at L3-4, L4-5, and L5-S1 and no more than two spinal levels can be done 
at any one time and the request is for three spinal levels. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and each additional facet joint (64636).
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 you are unable to walk and require IRF services to 
overcome mobility issues and address functional deficits. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device. 
 
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 current evidence-based medical 
guidelines and peer-reviewed literature do not fully support the use of the Minuteman interspinous fusion 
device procedure over the gold standard of lumbar fusion. There is a lack of large-volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. 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 a Minuteman device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on September 8, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
without the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided 
on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 15, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and request 
payment of the claim. The Plan denied your request. The Plan says the enrollee was referred by an OON 
provider. Services are covered when they are provided by a participating provider. The Plan had network 
providers available to perform these services.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on November 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injection (64495). 
 
You asked the Plan to pay for the facet joint injection . You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a 
time period, which includes all procedures that are performed during the same day.  
 
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 facet joint injection. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does not have a covered 
indication for the requested bilateral lumbar facet joint injections as requested.  
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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the facet joint injection (64495).
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. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitative, and medical needs (combined complexity) does not require 
an acute hospital inpatient rehabilitative stay with an interdisciplinary approach to rehabilitative care. While the 
enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitative needs can be provided 
in a lower intensity and alternate setting such as 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 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: Favorable

 
We decided that the Plan has to approve the acute inpatient hospital care beginning May 28, 2023. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says that the services are not medically necessary. 
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient care are met. Our physician reviewer found 
the enrollee presented to the emergency department (ED) on May 28, 2023 with weakness. He was found to be 
hypotensive and had a urinary tract infection. He was treated with intravenous (IV) fluids and antibiotics. The 
records show 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 been met. Therefore, we decided that the Plan 
has to approve the acute inpatient hospital care beginning May 28, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital inpatient evaluation and management service 
(99232) provided on December 12, 2022. 
 
You asked the Plan to pay for inpatient evaluation and management visit. You say that the same date of service 
was paid with a Place of Service (POS) code of 21. The Plan denied your request. The Plan says the enrollee 
was not a hospital inpatient at the time this service was performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital inpatient care, per day, for 
the evaluation and management of a patient. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, for dates of service prior to January 1, 2023, code 99232 is only for use in the inpatient hospital Place of Service. The enrollee was in 
outpatient observation status at the time this service was performed. Based on this information, we decided that 
Medicare rules for coverage of inpatient evaluation and management visit have not been met. Therefore, we 
decided that the Plan does not have to pay for a hospital inpatient evaluation and management service (99232) 
provided on December 12, 2022.