Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require 
frequent rehab physician management, or an interdisciplinary approach for rehab 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 above. 
 
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 physician reviewer found 
that you were admitted to the acute hospital with an ischemic foot ulcer. A femoral-distal popliteal bypass graft 
was successfully placed. The wound vac has been removed. The right lower extremity has improved. The 
documentation does not support that the complexity of your nursing, medical and rehabilitation needs require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program.
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) scan of 
the neck (70498). 
 
You asked the Plan to pre-approve this service. You say that a CTA scan of the neck is medically necessary. 
The Plan denied your request. The Plan says a CTA scan of the neck 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 this service. Our reviewer says that a 
CTA scan of the neck is not medically necessary. Our physician reviewer found that a CTA scan of the neck is 
not indicated for the screening for carotid disease in an asymptomatic patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomographic angiography (CTA) scan of the neck (70498).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; with meniscectomy (medial 
OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage 
(chondroplasty), same or separate compartment(s), when performed (CPT Code 29881). 
 
You asked the Plan to pre-approve the service. You say that given the history, clinical examination, imaging 
study results and persistent symptoms that are affecting the patient's ability to perform daily activities 
diagnostic and surgical arthroscopy of the knee is considered medically necessary. The Plan denied your 
request. The Plan says the service is not 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence based medical literature would not support surgery at this time. No specific 
functional limitations are noted. There is no discussion of mechanical symptoms. Records submitted for review 
do not include imaging studies, or evidence of maximized conservative treatment, including prescription 
NSAIDs, physical therapy or home exercise. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request at this time. Therefore, this request for 
right knee surgery (CPT code 29881) would not be considered 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any 
meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate 
compartment(s), when performed (CPT Code 29881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe inserts (L3000). 
 
You asked the Plan to pre-approve shoe inserts. You say that you need this to reduce your pain. The Plan 
denied your request. The Plan says this item is not covered for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The specific inserts requested are covered only if 
they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper 
functioning of the brace. 
 
Records show that you do not wear a leg brace. Although orthotics may be appropriate for you, neither 
Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan 
does not have to pre-approve shoe inserts (L3000).
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 (CPT Code 64635 x1)
and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or
CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
(CPT Code 64636 x1).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the information received shows you received this treatment one (1) month ago. The Plan
states treatments are given six (6) months apart.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. The information received shows
you received this treatment one (1) month ago. Treatments are given six (6) months apart. 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 (CPT Code 64635 x1)
and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or
CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
(CPT Code 64636 x1).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injection services (64490). 
 
You asked the Plan to pre-approve the facet injection services. You say that the records provided support the 
need for the requested injection services. The Plan denied your request. The Plan says the requested injection 
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 the facet injection services. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is documentation of radiculopathy. The review has determined that the 
enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of 
the facet injection services. It is not medically necessary or reasonable for this enrollee to have the facet 
injection services 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 injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet injection services (64490).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 11, 2019, to 
September 13, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the enrollee did not meet criteria for inpatient care. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was admitted on September 11, 2019, for treatment of hyperkalemia, renal failure, 
and supratherapeutic international normalized ratio. Initially she was admitted as an observation-status case but 
then converted to an inpatient-status on September 12, 2019. Her stay was unremarkable, and she quickly 
recovered; being discharged home after a two-night stay. The review has determined that the record showed 
that at the time of inpatient admission the admitting physician reasonably expected that the patient'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 pay for the acute inpatient hospital care provided from September 11, 2019, to September 13, 2019.  
 
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 pay for the lab services provided on February 28, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 the requested CPT codes are not supported in the medical record. Specifically, the records do not 
show that the lab services were performed on a blood specimen. The records show that a urine specimen was 
collected. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 
28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the aspiration and/or injection of large joint (20610, J0702, 
A4215, 99214) provided on November 11, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the aspiration and/or injection of large joint. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 the aspiration and/or injection of large joint 
(20610, J0702, A4215, 99214) provided on November 11, 2019, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT Code 64493), injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (CPT Code 
64494) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 
innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional 
level(s) (List separately in addition to code for primary procedure) (CPT Code 64495). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your records lack documentation supporting facet-mediated back pain. The Plan states 
there is no documentation that the pain is aggravated by hyperextension, rotation or lateral bending of the 
spine. 
 
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 there is no documentation of findings on physical examination supporting facet-mediated pain; and there 
is no documentation that the pain is aggravated by hyperextension, rotation, or lateral bending of the spine, 
depending on the orientation of the facet joint at that level. The review has determined that the medical records 
provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 CPT Code 64493, CPT Code 64494 and CPT Code 64495.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Apple watch. 
 
You asked the Plan to pre-approve an Apple watch. You say that your doctor needs to monitor your heart rate 
for 30 days to determine if you will need a pacemaker. The Plan denied your request. The Plan says a 
smartwatch is an emergency communication system that does not serve a diagnostic or therapeutic purpose and 
is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an Apple watch.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is a lack of imaging confirming nerve compression/stenosis. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural injections are covered if the indications 
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 the injection. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee had a recent plain x-ray and the symptomatology and physical exam support the 
performance of an ESI. It is 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 injection have been met. Therefore, we decided that the Plan has to pre-
approve a spinal injection for the enrollee.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services by physician also performing 
a procedure, additional 15 minutes (99153), moderate sedation services by physician also performing a 
procedure, patient 5 years of age or older, first 15 minutes (99152), needle biopsy or removal of lymph node 
(35805) and Computed tomography guidance for needle placement (77012) provided on January 28, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for moderate sedation services by physician also performing a procedure, additional 
15 minutes, moderate sedation services by physician also performing a procedure, patient 5 years of age or 
older, first 15 minutes, needle biopsy or removal of lymph node and computed tomography guidance for needle 
placement. You say that the provider is not responsible for obtaining authorization. The Plan denied your 
request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-
network provider. There are multiple in-network providers that can render this service in the member's area. 
 
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 has network providers 
available who can provide 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 the moderate sedation services by physician also 
performing a procedure, additional 15 minutes (99153), moderate sedation services by physician also 
performing a procedure, patient 5 years of age or older, first 15 minutes (99152), needle biopsy or removal of 
lymph node (35805) and Computed tomography guidance for needle placement (77012) provided on January 
28, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care services provided by a 
participating provider on February 13, 2020, to June 30, 2020. 
 
You asked the Plan to waive the copayment for vision care specialist services. You say that you think you are 
being over charged. The Plan denied your request. The Plan says the correct copayments have been applied. 
 
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 $40 
copayment for vision care/in-network/specialist.  
 
You have been asked to pay a $40 copayment for each vision care specialist services. The total amount you are 
being asked to pay is $160. Vision care specialist services fall within the vision care/in-network/specialist 
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. 
Therefore, we decided that the Plan does not have to waive the copayment for vision care services provided by 
a participating provider on February 13, 2020, to June 30, 2020.
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 the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 above. 
 
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 you were admitted for pancreatitis and cholangitis. Your medical problems are stable. 
There are no identified problems that require inpatient medical management. There are no complex nursing or 
rehabilitation needs. The documentation supports that you may require additional physical therapy and 
occupational therapy, but do not require an intensive rehabilitation therapy program. 
 
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.