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

 
We decided that the Plan does not have to pre-approve the lower extremity revascularization. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support the medical necessity of the treatments in question. The 
documentation does not suggest the patient is having significant symptoms related to lower extremity arterial 
perfusion. The patient has a history of neuropathy and history of back surgery, knee surgery, and neck surgery. 
The pedal pulses are documented to be 2+ bilaterally. The ankle brachial indices are essentially normal with an 
impression of mild disease bilaterally. There is no sign of limb threat.  Therefore, the health plan determination 
cannot be overturned on the basis of medical necessity. 
 
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 the lower extremity revascularization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. The Plan denied your request. The Plan says the requested drug is 
self-administered and does not fall under Part B coverage. The Plan says that they do not administer pharmacy 
benefits for the enrollee. 
 
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 Ozempic.  
 
Benefits for Ozempic 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the home health services provided from April 4, 2021, through 
April 8, 2021. 
 
You asked the Plan to pre-approve the home health services. You say that issues with the third-party billing 
company and the Health Plan have caused the claims to not be paid. The Plan denied your request. The Plan 
says that this service was sent to the Plan in error and needs to be sent to their third-party billing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the documentation does not show evidence to support that the claim 
that was denied was a Request for Anticipated Payment (RAP) and no other evidence to clearly support when 
the RAP was submitted to the Plan. Therefore, we decided that the Plan has to pre-approve the home health 
services provided from April 4, 2021, through April 8, 2021.  
 
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: 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 feel that this level of care is medically necessary 
for your recovery. The Plan denied your request. The Plan says the medical records do not support the need for 
an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to the acute hospital on January 24, 2023, with a urinary tract infection causing pyelonephritis and sepsis. Therapy notes show that the enrollee needs contact guard 
assistance with bed mobility, minimal assistance for transfers and walking up to 50 feet with a walker but 
requires prolonged rest breaks due to fatigue. 
 
The enrollee is medically stable and does not need a rehabilitation physician's supervision 3 times a week in an 
IRF. There are no acute skilled nursing needs identified or documented. At the current high functional level, 
the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days 
per week with multidisciplinary approach 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on July 10, 2022, to 
July 15, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $295 
copayment per day for days 1-6 for inpatient hospital care. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctors order. The day before you are discharged is your last 
inpatient day. There were 5 days. 5 x $295 = $1,475. Therefore, results in the total cost sharing amount of 
$1,475. 
 
 
 
 You have been asked to pay a $295 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital care 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 inpatient 
hospital stay on July 10, 2022, to July 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc. 
 
You asked the Plan to pre-approve Myobloc. You say that the clinical information provided supports the need 
for the requested drug. The Plan denied your request. The Plan says they do not administer pharmacy benefits 
for the enrollee. 
 
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 Myobloc.  
 
Benefits for Myobloc 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thyroidectomy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that thyroidectomy may be indicated for a variety of benign and malignant conditions. Benign nodules, 
as this enrollee has, are usually not removed unless they grow over time or cause symptoms. A nodule that is 4 
cm or larger should generally be removed with thyroid nodule surgery. The documentation does not support 
that the proposed thyroidectomy is medically necessary for the enrollee 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thyroidectomy.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 93010 and 99285) 
provided to the enrollee on December 11, 2021. 
 
You asked the Plan to pay for the services. You say that the attached notes and medical records state that this 
patient went into the emergency room on this date and was seen by the physician for a medically necessary 
procedure. The Plan denied your request. The Plan says the diagnosis code on the claim do not support the 
billed procedure codes. 
 
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 the denied codes is: 
 
CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires a medically 
appropriate history and/or examination and high level of medical decision making 
 
CPT 93010: 
 
Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only  
We asked our coder 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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record does not 
support the level of care for CPT 99285 for evaluation and management. The documentation would support 
CPT 99284. In terms of CPT 93010, the medical record does not include enough documentation to confirm the 
electrocardiography (ECG) performed was not a printout of results done by ECG machine. Therefore, this 
procedure cannot be verified. 
 
We looked at this coder'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 pay for emergency room services (procedure code 93010 and 99285) provided to the enrollee on 
December 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional features for a prosthesis (L5828, L5845, 
L5848, L5856, L5981 - microprocessor and flex walk system). 
 
You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no reason why a microprocessor knee would be 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 features. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no current or historical data indicating that the enrollee is a K3 community ambulator with 
variable cadence and ability to avoid the usual community hazards. 
 
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 features have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional features for a prosthesis (L5828, L5845, L5848, L5856, L5981 - microprocessor 
and flex walk system).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment rendered on October 
10, 2022. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The file shows that the ambulance company did not provide transport services on October 10, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment rendered on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve an Intracept Procedure. You say that the denial of the Intracept procedure is 
unwarranted and unsupported by the enrollees current medical status and current peer-reviewed literature. 
Given the previously submitted history, physical examination and the radiologic findings, the Intracept 
Procedure is medically necessary and supported by strong science. The Plan denied your request. The Plan says 
unproven and not medically necessary procedures are not covered by Medicare. 
 
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 an 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 and investigational. There is more research 
needed due to insufficient evidence of 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 an Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging 
guidance, first two vertebral bodies, lumbar or sacral (64628).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy provided on March 8, 2021. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says physical therapy is 
not medically 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 physical therapy. 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 that the additional visits are not medically necessary for a chronic 
condition with minimal deficits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve the mattress. You say that the mattress is medically necessary. The Plan 
denied your request. The Plan says the mattress is not 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 mattress. Our physician reviewer 
found per L33642, as the enrollee does not have pressure ulcers. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the powered pressure-reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PWC, group 1 standard, portable, sling/solid seat and 
back, patient weight capacity up to and including 300 pounds (K0813). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says the power wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our physician 
reviewer found here is no clear indication that the enrollee is unable to accomplish mobility related self-care 
tasks with the enrollee's current manual wheelchair. Additionally, there is no indication that the enrollee has ample space in the enrollee's home to operate a PWC safely. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve PWC, group 1 standard, portable, sling/solid seat and back, patient weight 
capacity up to and including 300 pounds (K0813).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(CPT code 78452). 
 
You asked the Plan to pre-approve the imaging. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 the imaging. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no evidence provided that would support the need for radionuclide stress testing at this 
time. In summary, there is insufficient documentation to support the medical necessity for the requested cardiac 
stress testing in this enrollee's clinical management. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (CPT code 78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external counterpulsation (ECP), per treatment 
session (G0166). 
 
You asked the Plan to pre-approve an ECP. You say that the enrollee has previous history of coronary artery 
disease and CABG. He has also been having angina and diminished breath sounds. Additionally, he has a 
history of peripheral vascular disease. The Plan denied your request. The Plan says the request does not meet 
the Medicare or health plan coverage criteria. ECP 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 an ECP. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the appropriateness and medical necessity of ECP in the management of this 
enrollee. Documentation does not indicate that the enrollee has Class III or IV angina, or angina at rest or 
minimal exertion; nor is there evidence that the enrollee needs further revascularization. As such, it is 
premature to consider ECP. In summary, there is insufficient documentation to support the medical necessity 
for the use of ECP in this enrollees clinical management. 
 
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 ECP have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an external counterpulsation (ECP), per treatment session (G0166).