Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to be moved out of your current facility 
and you need 24-hour care. The current rehabilitation is only 30 minutes a day and you believe you need more 
than 30 minutes a day. The Plan denied your request. The Plan says the records show the enrollee does not 
need to be seen by a rehabilitation doctor 3 times a week. The records do not show that the enrollee can yet 
tolerate or need 3 hours of therapy a day, 5 days a week. The enrollee does not need an intensive team for their 
care. The enrollee can safely receive the services they need in other settings like a skilled nursing facility, home 
with home health services or home with outpatient therapy. 
 
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 enrollee requires pain control and walking as tolerated. The enrollee has an 
uncomplicated but painful pelvic fracture. The enrollee does not require intensive rehabilitation services. The 
enrollee does not require frequent physiatry oversight and does not require rehabilitation nursing. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (CPT code 64628). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because there is little evidence in 
the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. The Plan 
states it is not an accepted standard of medical practice for the diagnosis or treatment of back pain and it is 
considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation does not support actual formal surgical ablation of pre-designated basivertebral 
nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the request for intracept intraosseous basivertebral nerve ablation at L2, L3, and L4 is 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (CPT code 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthesis and socket. 
 
You asked the Plan to pre-approve the replacement prosthesis and socket. You say that the replacement 
prosthesis is medically necessary. The Plan denied your request. The Plan says the existing prosthesis is 
covered under manufacturer's warranty and a replacement is not supported by the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that supplier-produced records, even if signed by the 
prescribing physician/practitioner, and attestation letters (e.g. letters of medical necessity) are deemed not to be 
part of a medical record for Medicare payment purposes. Rules also state that no more than two socket inserts 
are allowed for a given prosthesis. 
 
We looked at the file and Medicare rules. The existing foot is less than 24 months old and is covered under the 
manufacturer's warranty. Two sockets have already been provided, and the additional requested socket is non-
covered. The records provided are from the supplier and do not support the request based on Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the replacement prosthesis and socket have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement 
prosthesis and socket.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have pay an additional amount for the x-rays and mammograms provided 
from February 7, 2022, to March 21, 2022, by the out-of-network providers. 
 
You asked the Plan pay an additional amount for the diagnostic services. You say that you are being billed 
because your insurance has already paid the amounts agreed upon contractually. You say that you are not 
responsible for any more of that. You also say that this is why you have insurance. The Plan denied your 
request. The Plan says the provider in this case is out-of-network. The Plan also says that the claims processed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that non-contract providers must accept as payment 
in full payment amounts applicable in Original Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have pay an additional amount for the x-rays and mammograms provided from February 7, 2022, to March 21, 2022, by 
the out-of-network providers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement group 3 power wheelchair and 
accessories (K0856, E2361, E1028x2, E1002, E2300, E2620, E0955, E0953, E2310, E2624). 
 
You asked the Plan to pre-approve a replacement group 3 power wheelchair and accessories. You say that the 
enrollee has a power wheelchair that no longer meets her positioning needs. The Plan denied your request. The 
Plan says the enrollee was approved for a group 2 power wheelchair in January 2022. There is no 
documentation that this chair is damaged or not functioning properly. The Plan also says the current wheelchair 
has not reached reasonable useful life, as it is less than 5 years old. 
 The Plan must follow Medicare rules. Medicare rules the reasonable useful lifetime of durable medical 
equipment is determined through program instructions. In the absence of program instructions, A/B MACS (B) 
may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. 
 
The records show that you were approved for a group 2 power wheelchair in January 2022. Medicare rules say 
the reasonable useful lifetime of DME cannot be less than 5 years. This means that Medicare rules for coverage 
of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement 
group 3 power wheelchair and accessories (K0856, E2361, E1028x2, E1002, E2300, E2620, E0955, E0953, 
E2310, E2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary because the enrollee 
needs to regain their strength to return home. The Plan denied your request. The Plan says the records state the 
enrollee is not medically ready to leave the hospital. The request does not meet Medicare guidelines for 
medical necessity because the enrollee's medical condition requires further evaluation and treatment in the 
acute care hospital. The enrollee must complete their full course of acute hospital treatment. 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. The enrollee does not need 3 hours a day, 5 days a week of therapies with multidisciplinary 
approach in an IRF. The enrollee needs a prolonged course of rehabilitation with baseline needing assist for 
function. 
 
Documentation does not support the medical necessity due to lack of medical complexity and nursing needs for 
admission to an IRF. While the enrollee would benefit from physical therapy and occupational therapy the 
enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as 
continuation in a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
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 based on IRF criteria. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. You are 
functioning at a level commiserate with your injuries and weight-bearing restrictions. Your care needs can be 
met 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 pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the items in dispute are 
medically necessary The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF 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 the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that you have wound care needs and medical 
monitoring needs in which skilled nursing assessment would be required. Additionally, you have functional 
impairment and requires skilled therapy. From a practical standpoint, you would require daily skilled services 
on an inpatient basis in a SNF. 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 been met. The Plan must continue 
coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper 
notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has 
to pre-approve SNF care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on February 22, 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 procedure code 99202 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99202 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99202 is not supported in the medical record. Specifically, the records show that 
procedure code 99205 was billed on July 29, 2021; therefore, a new patient office visit for the date of service at 
issue does not apply. 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 office visit rendered on 
February 22, 2022.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care. 
The Plan says that, once deemed appropriate, transfer to a lower level of care for rehabilitation or skilled 
services can be considered. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from January 1, 2022, to 
January 28, 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 that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services 
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion 
therapy rendered from January 1, 2022, to January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Purewick catheters (CPT code A4328). 
 
You asked the Plan to pre-approve the Purewick catheters. You say that you are experiencing bed sores in your 
lower pelvic area due to not being able to relieve yourself outside of the bed. The Plan denied your request. The 
Plan says they were unable to obtain an order and/or clinical information for the request. 
 
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 Purewick catheters. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not indicate that the request meets the coverage criteria. The 
review has determined that the items/services at issue in this case are 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 the Purewick catheters have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Purewick catheters (CPT code A4328).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70470 billed for date of service January 17, 
2022. 
 
You asked the Plan to pay for procedure code 70470. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for code 70470 is bundled into payment for code 0042T.  
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 70470 
is a column II code to column I code 0042T. 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 70470 billed for date of service January 17, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve the repeat ESI services. You say that the records provided support the need 
for repeat ESI services. The Plan denied your request. The Plan says the requested injection services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs are covered for certain clinical 
indications.  
 
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 repeat ESI services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the previous epidural 
steroid injection provided 80% pain relief for a period of only three weeks. The review has determined that the 
records showed that the first injection did not directly and significantly provide improvement of the condition 
being treated with 50% sustained improvement in pain relief and/or improvement in function measured range 
of motion baseline for at least three (3) months. The records show that the enrollee failed to respond well to the 
initial ESI and there was no request for another injection made within 14 days to be performed using a different approach, level, and or medication.  The medical necessity of a second injection is not documented in the 
medical records 
 
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 repeat ESI services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repeat epidural steroid injection (ESI) services.