Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits.. You say that the services are necessary. 
The Plan denied your request. The Plan says the services are not necessary. 
 
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 additional physical therapy 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 requested additionally therapy is not generally 
accepted as specific and effective therapy for the patients condition. The patient has had prior therapy for this 
condition and it appears that the patient does not require the ongoing unique skills of a professional therapist to 
safely and effectively provide treatment. Patient is noted to have improved gait and transfers to a level that does 
not require ongoing skilled therapy. Services do not need to be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. The patient and caregiver have been educated in a home 
exercise program and the requested services are not part of a maintenance program. The specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain the patient's current condition or to prevent or slow further 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 additional physical therapy visits. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ten (10) additional physical therapy visits.
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 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 Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. This enrollee does not require the services on an inpatient basis, in a skilled 
nursing facility setting. Services in a long-term care facility or assisted living facility on a part time basis 
appears appropriate in this case. 
 
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 pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that this patient would be equally well served at an alternative level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show the safety and efficacy of the device. There 
is no documented spinal instability. The device is not needed in this case. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete ultrasound of the retroperitoneal (76770) 
provided on April 6, 2020. 
 
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration because the member 
had multiple exams on the same date of service. The Plan denied your request. The Plan says the 
documentation does not support that this service was rendered on the billed 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. 
 
In this case, the CPT Code Manual definition of code 76770 is ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation; complete. 
 
We find that CPT code 76770 is not supported in the record. Specifically, the record indicates that a different 
service was rendered by this provider on the billed date of service. The record indicates that a limited 
ultrasound was rendered. This does not meet the definition of CPT code 76770. Based on this information, we 
decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the 
Plan does not have to pay for a complete ultrasound of the retroperitoneal (76770) provided on April 6, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on September 17, 2020 after a fall. The physical therapy note dated September 18, 2020 states she is 
independent with stand to sit, sit to stand, supine to sit, sit to supine, and rolling. She needs maximal assist with 
bathing, supervision with upper body dressing, and modified assist with lower body dressing. She does not 
have skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. 
As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special pump services rendered on September 21, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status 
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. 
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on September 
21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) cleaning 
device. 
 
You asked the Plan to pre-approve the cleaning device. You say that you do not have anyone to help you with 
the cleaning. The Plan denied your request. The Plan says the device is not primarily medical in nature. 
 
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 a continuous positive airway pressure (CPAP) cleaning 
device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stocking/sleeve (CPT Code 
A6549). 
 
You asked the Plan to pre-approve the gradient compression stockings. You say that these compression 
stockings fits you and the others you could not get over your toes. The Plan denied your request. The Plan says 
this item is not covered under Medicare or the Health Plan. 
 
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 gradient compression stockings have not been met. The rules 
also say that gradient compression stockings (A6530, A6533-A6544, A6549) are examples of wound care 
items which are non-covered under the surgical dressing benefit because they do not meet the statutory 
definition of a dressing. Therefore, we decided that the Plan does not have to pre-approve gradient compression 
stocking/sleeve (CPT Code A6549).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the spinal canal and contents (72156). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because this MRI is 
necessary for you to no longer be in pain. The Plan denied your request. The Plan says the requested cervical 
MRI with and without contrast is not the correct MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable and necessary. Our physician reviewer found the MRI with contrast 
is not necessary as far as the records support. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the spinal canal and contents (72156).  
 
Please note, the Plan has stated that an MRI of the spinal canal and contents, cervical; without contrast material has 
been approved. You may contact the Plan for more information regarding this service.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
pancreatic insufficiency and abnormal hepatic function panel. The medical documentation notes no abdominal 
pain and a normal abdominal  physical examination.  A differential diagnosis and treatment plan related to this 
test were not discussed. Without this documentation, medical necessity of the requested MRI is not supported. 
 
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 magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on September 16, 2020 for planned revision and antibiotic spacer removal and a right 
hip hemiarthroplasty. There is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. There are no services available at the LTACH that the enrollee requires 
that are not available at the health care setting being offered by the health plan. The requested LTACH services 
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and 
able to be furnished safely and effectively only on an inpatient basis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an earlier appointment for a complete cyst excision. 
 
You asked the Plan to pre-approve the requested service. You say that your infection is getting worse. The Plan 
denied your request. The Plan says it is recommended to wait 4-6 weeks after drainage before a complete cyst 
removal. 
 
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 service. Our physician 
reviewer found that the documentation shows that it is safe and effective for you to wait until the scheduled 
appointment.  It is not medically necessary for you to have an appointment sooner than your already scheduled 
appointment on October 14, 2020. 
 
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 service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an earlier appointment for a complete cyst excision.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy (45380) provided on January 9, 2020. 
 
You asked the Plan to pay for a colonoscopy. You say that the provider is certified with Medicare. The Plan 
denied your request. The Plan says the provider is not registered as an ambulatory surgical center. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that this service is not supported in the medical record. Specifically, the record shows that the provider 
in this case is billing on an institutional claim form as an ambulatory surgical center, but the provider is not an 
ambulatory surgical center. Based on this information, we decided that Medicare rules for coverage of a 
colonoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a colonoscopy 
(45380) provided on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options and attachments.You asked the Plan to pre-approve these services. You say that this is medically necessary.The Plan denied your request. The Plan says that you do not have medical need for multiple power options.The Plan must follow Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power options are covered if the above criteria are met. We looked at the file and Medicare rules. The file indicates you have not requested any power options and therefore a wheelchair with multiple power options is not required. 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 Group 3 power wheelchair with multiple power options and attachments
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 12, 2020 to April 24, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says that inpatient criteria were not met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the records show that the enrollee had sufficient acute metabolic and physical abnormalities to require admission.  Admission and hospitalization was both 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from April 12, 2020 to April 24, 2020. 

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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve additional non-emergent transportation trips. You say that you are 
requesting review of denial of services. The Plan denied your request. The Plan says you exhausted your 
benefit. 
 
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 ten (10) one-way 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. The 11th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve ten (10) 
additional non-emergent transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 3, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed for CPT code 81479 
for date of service March 3, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 3, 2020.