Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom prosthetic partial hand finger prosthesis. 
 
You asked the Plan to pre-approve the custom prosthetic partial hand finger prosthesis. You say that the code in 
the authorization request must be used to represent the item that is required. You say that the proposed Point 
Design partial finger prosthesis is the least level of technology available to meet your daily needs. You say that 
this requested type of prosthesis is passive, positional, and is not body-powered or myoelectric. The Plan 
denied your request. The Plan says that the code being used in the authorization does not match the item 
requested. 
 
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 the custom prosthetic partial hand 
finger prosthesis. Our reviewer says that the requested items are considered medically reasonable and necessary 
in this case. Our physician reviewer found that the criteria is met for the most basic digit prosthesis to meet 
your need to grasp objects. It should not be myoelectric or powered. The need for improved grasp function is 
clearly documented. 
 
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 custom prosthetic partial hand finger prosthesis have been met. Therefore, 
we decided that the Plan has to pre-approve a custom prosthetic partial hand finger prosthesis.  
 
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the surgical assistant services provided for removal of PMT depth 
electrodes and bolts provided on June 23, 2020, billed with CPT code 64999. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that this was billed correctly. The 
Plan denied your request. The Plan says that payment is not allowed for this service because it was billed 
without a CPT code or a description of the 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. Unlisted CPT codes are acceptable when there is 
no existing code which adequately describes the services.  
 
In this case, the CPT Code Manual definition of code 64999 is Unlisted procedure, nervous system. 
 
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 services as billed. Our reviewer says that 
the services rendered are not adequately described by any existing CPT code. Our physician reviewer found the 
enrollee has a diagnosis of Epilepsy, unspecified, not intractable, without status epilepticus. The procedure 
involved unscrewing the existing bolts and removal of electrodes along with the bolts with a bolt remover. 
There is not an appropriate code for removing subdural stereo-EEG electrodes unless a bone flap is lifted 
(61535). In the absence of a craniotomy for removal of the electrodes, the use an unlisted code (64999) is 
acceptable. 
 
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 as billed have not been met. Therefore, we decided that the Plan has 
to pay for the surgical assistant services provided for removal of PMT depth electrodes and bolts provided on 
June 23, 2020, billed with CPT code 64999.
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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for weakness and diarrhea and was treated for COVID 19 and sepsis. Medical conditions are stable. 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
 
 
 
 
 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical stimulation device (E0766). 
 
You asked the Plan to pre-approve an electrical stimulation device. 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 follows Medicare rules. Medicare rules say that tumor treatment field therapy is covered for the 
treatment of newly diagnosed GBM only when specific criteria is 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 electrical stimulation device. Our 
reviewer says that the services are not medically necessary.  
 
 
Our physician reviewer found the rule states "Tumor treatment field therapy (E0766) will be denied as not 
reasonable and necessary for the treatment of recurrent GBM." You have been diagnosed with recurrent GBM. 
 
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 electrical stimulation device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electrical stimulation device (E0766).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepercutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650) and electronic analysis of implanted neurostimulator pulse generator/transmitter (95972).You asked the Plan to pre-approvethe services. You say that the services are necessary.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 in this case, the member has a history of low back pain. They are noted not to have adequately respondedto injections, PT and pharmacotherapy. However, it is not clear if the member had been seen for a surgical evaluation/consultation regarding their low back symptoms. Per the applicable NCD and LCD a SCS is generally reserved as a therapy of "last resort" when other interventions have not been successful (or are contraindicated) in the management of pain. In this case, as noted previously, there was no indication of a surgical evaluation/consultation regarding the member's low back symptoms/pain. It therefore cannot be determined if they may be a candidate for surgical intervention to treat their condition at this time. Likewise, the member is also noted to have a mass in their thoracic spine and it is unclear from the information provided if their symptomology may also be associated with thesefindings and if so--if intervention of that problem could ameliorate their condition. Ultimately, the information provided for review in this case does not otherwise show that the requirements of the NCD/LCD for coverage of this service have been met.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-approvepercutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650) and electronic analysis of implanted neurostimulator pulse generator/transmitter (95972).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5211) provided on July 2, 
2020. 
 
You asked the Plan to pay for the maxillary partial dentures. You say that the services you received were 
medically necessary for your condition. The Plan denied your request. The Plan says the services you received 
are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
maxillary partial denture (D5211) provided on July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient hospital care provided from 11pm on 
February 17, 2020, to February 18, 2020. 
 
You asked the Plan to pay for the final day of inpatient care. You say that this admission should be approved 
for payment. The Plan denied your request. The Plan says all care was approved up until the declaration of 
stability. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 final day of inpatient care. Our reviewer 
says that the enrollee was declared stable for transfer at 11pm on February 17, 2020. Our physician reviewer 
found there was no documentation that would support the patient being unstable for transfer after the note that 
deemed the patient as being stable. 
 
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 final day of inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pay for the continued inpatient hospital care provided from 11pm on February 17, 2020, 
to February 18, 2020.
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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer can be considered soon when the enrollee is more stable and the 
weaning potential is more clearly observed. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Veltassa (J8499). 
 
You asked the Plan to pre-approve Veltassa. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Veltassa (J8499).  
 
Benefits for Veltassa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gmaunex-C. 
 
You asked the Plan to pre-approve Gmaunex-C. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gmaunex-C.  
 
Benefits for Gmaunex-C may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient post-stabilization care provided on July 1, 2020 
to July 3, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient post-stabilization care. You say that you are asking for review and 
make the necessary corrections to the system to process additional payment due. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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 inpatient post-stabilization care provided on 
July 1, 2020 to July 3, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care provided 
from June 1, 2020, to June 13, 2020. 
 
You asked the Plan to pre-approve the SNF care. You say that it is felt that Medicare payment can be made for 
these services. The Plan denied your request. The Plan says Medicare coverage was approved for some of the 
dates at issue. However, the remaining days are considered custodial 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found from a nursing perspective, the 
beneficiary received oral medications.  The beneficiary had stable vital signs. Regarding rehabilitation services, 
the beneficiary did not require any daily skilled PT or OT intervention for the dates in question after evaluation. 
She required one assist with functional mobility. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) care provided from June 1, 2020, to June 13, 
2020.
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 as a practical matter, you are receiving the 
necessary services on an inpatient basis in an acute rehabilitation 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 skilled nursing facility (SNF) care.
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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
NSTEMI and had coronary artery bypass grafting. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a neurostimulator electrode array 
(63650). 
 
You asked the Plan to pre-approve the implantation of a neurostimulator electrode array. You say that this is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is covered if the implantation 
of the stimulator is being used only as a late resort (if not a last resort) for chronic intractable pain; and other 
treatment modalities (pharmacological, surgical, physical, psychological therapies) have been tried and did not 
prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient. 
 
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 implantation of a neurostimulator 
electrode array. Our reviewer says that the requested service is not medically necessary. Our physician 
reviewer found the member is noted to have a longstanding history of chronic pain (and had apparently 
previously undergone SCS placement a decade ago), there is no noted history of surgical intervention (or even 
surgical consultation) for the member's symptoms/complaints. It therefore cannot be determined that placement 
(or trial) of a SCS at this time would be used only as a last resort for this member 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 the implantation of a neurostimulator electrode array have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the implantation of a neurostimulator 
electrode array (63650).