Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s), 
not including neurolytic substances, including needle or catheter placement, interlaminar epidural or 
subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT) (62323). 
 
You asked the Plan to pre-approve injections. You say that the requested injections are necessary. The Plan 
denied your request. The Plan says the requested injections do not meet the requirements for approval. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the submitted records do not indicate that the enrollee has a history, physical examination, and 
concordant radiological image-based diagnostic testing that supports lumbar radiculopathy, radicular pain 
and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative 
disc disease, producing foraminal, central spinal stenosis, post-laminectomy syndrome, or acute herpes zoster 
associated pain. The records do not show that the enrollee has radiculopathy, radicular pain and/or neurogenic 
claudication is severe enough to greatly impact quality of life or function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), of diagnostic or therapeutic substance(s), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with 
imaging guidance (i.e., fluoroscopy or CT) (62323).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the ultrasound services. You say that the services should be covered as you 
disagree with the denial and would like to continue seeing the same provider. The Plan denied your request. 
The Plan says the services denied correctly as are non-emergent and the same care can be provided in-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 
ultrasound services to be provided by an out-of-network (OON) provider.
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 you are appealing the denial of an inpatient 
rehabilitation facility admission. The Plan denied your request. The Plan says inpatient rehabilitation admission 
is not considered medically reasonable or 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 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's nursing, medical and rehabilitation needs do not require an acute rehab 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can receive further 
services at a lower 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 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 pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies provided on April 1, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that the records support that this device is needed. 
The Plan denied your request. The Plan says the criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that TENS may be covered when certain criteria, as 
described in the Medicare rules section of this decision, are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the TENS supplies. Our reviewer says that the documentation does not support that the criteria for TENS treatment are met. Our physician reviewer found 
the enrollee is an 80-year-old woman with diagnoses that include Pain in unspecified hip, Muscle weakness 
(generalized), and Foot drop, left foot. The Initial Evaluation dated 2/23/22 includes a treatment plan for 
physical therapy 2 times per week for 6 weeks. The clinical documentation in the case file does not support that 
electrical stimulator supplies are medically reasonable and 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 TENS supplies have not been met. Therefore, we decided that the Plan does 
not have to pay for the transcutaneous electrical nerve stimulation (TENS) supplies provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the podiatry services. You say that the services should be covered as you 
disagree with the denial and would like to continue seeing the same provider. The Plan denied your request. 
The Plan says the services denied correctly as they are non-emergent and the same level of care can be 
provided in-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 
podiatry services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transesophageal echocardiogram (TEE). 
 
You asked the Plan to pre-approve the requested TEE. You say that it is felt that this testing is medically 
necessary. The Plan denied your request. The Plan says there is no clinical documentation that has been 
received to speaks to the necessity of imaging for the 
direction for the requested procedure. 
 
The Plan follows Medicare rules. Medicare rules say that TEE may be covered when the criteria for medical 
necessity listed in the Medicare rules section have 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 requested TEE. Our reviewer says 
that the requested TEE is not shown to be medically necessary. Our physician reviewer found the 
cardiovascular exam is unremarkable with no murmurs detected. Clinical guidelines do not support carrying 
out a TEE in this setting. In summary, there is no supportive evidence for the medical necessity of a TEE in this 
patients 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 requested TEE have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a transesophageal echocardiogram (TEE).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says you do meet Medicare medically necessary guidelines 
for a LDCT scan for lung cancer screening. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  We reviewed the file and the Medicare rules. We find that due to your age, you do not meet coverage criteria. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta injections. 
 
You asked the Plan to pre-approve Zilretta injections. You say that this is the only medication that will help 
instead of getting a double knee replacement. The Plan denied your request. The Plan says the requested 
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 Zilretta injections. Our reviewer says 
that the documentation does not support that the requested drug is medically reasonable or necessary. Our 
physician reviewer found you have a past medical history of bilateral knee osteoarthritis. You received bilateral 
Zilretta knee injections on February 21, 2022. Based on the medical records provided and the Medicare-
approved major drug compendia there is no documentation that the Zilretta injections at issue in this case meet 
Medicare criteria for medically reasonable and necessary. The efficacy and safety of repeat administration of 
Zilretta have not been demonstrated. Therefore, you do not meet criteria for the requested injections. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Zilretta injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11103 billed for date of service November 9, 
2021. 
 
You asked the Plan to pay for procedure code 11103. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 11103 is bundled into payment for code 56605.  
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 11103 
is a column II code to column I code 56605. 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 procedure code 11103 billed for date of service November 9, 
2021.
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 want to get better and live in your home. The 
Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. Your 
ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 that 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 did not experience 
post-operative complications. You do not require to level of supervision provided by a rehabilitation physician. 
Your medical and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute 
inpatient rehabilitation. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a 
week, or 15 hours over seven consecutive days. You have had a functional decline from your baseline level of 
function and would benefit from therapy. However, you do not require the intensity of services 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 22, 2021, to 
November 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like for the claim to be 
reprocessed and paid. The Plan denied your request. The Plan says the services were not referred by a network 
provider or approved in advance. The Plan also says the requested services were not urgent or emergent; 
therefore, the out-of-network services are not covered. 
 
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 home health services provided on October 22, 
2021, to November 19, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is the only available orthosis 
which can provide the enrollee with immediate return of functional use of his upper extremity. The Plan denied 
your request. The Plan says this item 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. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
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 you need SNF care prior to going to home. The Plan 
denied your request. The Plan says SNF care 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 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy (52001) provided on November 21, 
2021. 
 
You asked the Plan to pay for the cystourethroscopy (52001). The Plan denied your request. The Plan says 
procedure code 52001 is considered inclusive to procedure code 52214. 
  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 52001 is a column II code to column I code 52214; however, 52001 
was billed with a modifier.  
 
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 cystourethroscopy (52001). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the procedure report does not include enough documentation to support the cystourethroscopy with irrigation 
was a separate procedure from the cystourethroscopy with fulguration. 
 
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 cystourethroscopy (52001) have not been met. Therefore, we decided that 
the Plan does not have to pay for the cystourethroscopy (52001) provided on November 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services should be covered as you disagree 
with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as they are non-emergent and can be 
provided in-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 
an office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to a medical appointment. The Plan denied your request. The Plan says the benefit allows up to 24 one-way 
trips per calendar year, but each one-way trip must not exceed 50 miles. 
 
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 routine transportation up to 24 one-way trips, with each one-way trip not to exceed 50 
miles.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 93.8 miles from your residence which exceeds the 50-mile limit. Therefore, we decided that the Plan 
does not have to pre-approve additional mileage for routine transportation (A0170).