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

 
We decided that the Plan does not have to pre-approve placement of a sacral nerve stimulator (SNS). 
 
You asked the Plan to pre-approve the SNS placement. You say that you feel that this is necessary. The Plan 
denied your request. The Plan says this device is not covered for members with obstructive related physiology. 
 The Plan follows Medicare rules. Medicare rules say that SNS may be covered for enrollees with incontinence 
that is refractory to conventional treatments and is not caused by obstruction.  
 
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 SNS placement. Our reviewer says 
that the documentation does not support that coverage criteria are met. Our physician reviewer found the 
enrollee is a male with a diagnosis of benign prostatic hypertrophy (BPH) with urinary urgency. He stopped 
Flomax recently and experienced worsening incontinence. Urgency is well controlled with oxybutynin.  
 
The records do not support coverage for the Interstim device. This device is not covered for members with 
obstructive related physiology. Given the member stopped Flomax and experienced worsening symptoms, it is 
likely that obstruction contributes to the enrollee's symptoms. In addition, maximal conventional BPH and 
overactive bladder treatment has not been demonstrated. 
 
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 SNS placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of a sacral nerve stimulator (SNS).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76857) provided on November 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 76857 
is a column II code to column I code 76856. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (76857) provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (eg, 
corn or callus) (11055) provided November 11, 2011. 
 
You asked the Plan to pay for the foot care services. You say that the denial form does not give enough 
information as to the type of service you supposedly received. You did not receive treatment to your feet at this 
appointment. The Plan denied your request. The Plan says routine foot care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
foot care services have not been met. Therefore, we decided that the Plan does not have to pay for the paring or 
cutting of benign hyperkeratotic lesion (eg, corn or callus) (11055) provided November 11, 2011.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a rolling walker with contact guard assistance and are contact guard assist for 
transfers. Provided records do not document a significant decline in your functional status to necessitate daily 
inpatient skilled therapy services. You do not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Records do not document that services in the home or an assisted living facility with 
home health care or in a long-term care facility on a part time basis are not 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not document 
a trial and failure of three months of non-pharmacologic therapy or failure of joint aspiration and an intra-
articular corticosteroid injection. The records do not support that the Orthovisc is reasonable and medically 
necessary and safe and effective 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 Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the medically necessary services are available within the enrollee's 
network and there are no extenuating circumstances making it medically necessary to obtain the services out-
of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living; waiver, per diem (T2031) provided on 
February 27, 2022 to February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the assisted living services. You say that you received a denial letter and you 
would like to appeal. 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 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 the assisted living; waiver, per diem (T2031) 
provided on February 27, 2022 to February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being 
provided in the current acute care setting which is already approved. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 9, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 9, 2021.
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 the abdominal MRI. You say that this imaging is necessary. The Plan 
denied your request. The Plan says there has been no renal ultrasound or contraindication to other renal 
imaging. 
 
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 abdominal MRI. Our reviewer says 
that the requested imaging is not considered medically reasonable and necessary. Our physician reviewer found 
the enrollee is an 83-year-old with chronic kidney disease stage IV, with proteinuria. The records describe 
plans for renal ultrasound. MRI abdomen was requested. However, there was insufficient support made for this 
request. There was no record  of the ultrasound actually being performed and resulted which is a recommended 
initial test for the patient's history and presentation. Also, there was no indication from examination or previous 
testing to justify advanced imaging of the abdomen. Therefore, MRI abdomen will be considered not 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 the abdominal MRI 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert system. 
 
You asked the Plan to pre-approve a life alert system. You say that the requested device is medically necessary. 
The Plan denied your request. The Plan says the requested device is considered a convenience item primarily 
hygienic in nature or a device that is not primarily medical in nature and thus not covered under Medicare or 
the Plan. 
 
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 life alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on December 13, 2021. 
 You asked the Plan to pay for the outpatient services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The diagnosis code F23 is not listed as a supported ICD 10 for codes 80307 and G0480. The rules say that 
there are specific ICD-10-CM Codes that Support Medical Necessity. Diagnosis code F23 is not listed in the 
Medicare rule to support medical necessity. Furthermore, codes with status indicator 'Q4': 36415, 80053, 
84443, and 85025, are packaged services. Packaged APC payment if billed on the same claim as a HCPCS 
code assigned published status indicator "J1", "J2", "S", "T", "V", "Q1", "Q2", or "Q3". According to OPPS 
99285 has a status code of J2. Therefore, CPT code(s): 36415, 80053, 84443, and 85025, are not separately 
paid. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on 
December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. The Plan denied your request. The Plan says an 
epidural steroid injection is not medically necessary and does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 epidural steroid injections. Our 
reviewer says that epidural steroid injections are not medically necessary. Our physician reviewer found that 
there is no recent imaging, and the use of ultrasound guidance is not the standard of care. Therefore, the request 
is deemed not medically reasonable or 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (28298, 28308) provided November 9, 
2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 CPT code 28298, & 28308 is not supported in the medical record. Specifically, CPT 28298 would 
be inclusive to CPT 28297, which is the more extensive procedure. CPT 28380 would be inclusive to CPT 
28309, which includes multiple metatarsals. The Operative report does not support modifier 59 as a distinct 
separate procedure. Based on this information, we decided that Medicare rules for coverage of the surgical 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services 
(28298, 28308) provided November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation 
procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is an effective treatment for this 
enrollee's condition. The Plan denied your request. The Plan says there is not sufficient evidence to support this 
procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy administration, intravenous infusion 
technique; up to 1 hour, single or initial substance/drug (CPT code 96413), chemotherapy administration, 
intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) 
(CPT code 96415), and Ustekinumab, for intravenous injection, 1MG (CPT code J3358). 
 
You asked the Plan to pre-approve the medication. You say that there is documentation that the enrollee has 
been on Imuran and Entocort. The Plan denied your request. The Plan says Medicare requires failure of or 
intolerance (the drug makes you sick) to Immunomodulator or corticosteroids before Stelara can be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of Crohn's disease. The record provided does not indicate that the enrollee has failed treatment or were intolerant to immunomodulator or corticosteroid therapy, 
or failed treatment with a tumor necrosis factor blocker. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial 
substance/drug (CPT code 96413), chemotherapy administration, intravenous infusion technique; each 
additional hour (List separately in addition to code for primary procedure) (CPT code 96415), and 
Ustekinumab, for intravenous injection, 1MG (CPT code J3358).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy and sedation services rendered on December 3, 
2021. 
 
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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 
pay for the biopsy and sedation services rendered on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on March 15, 
2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on March 15, 2021.