Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you have permanent vertigo that makes it hard for 
you to stand. Using your walker is difficult due to knee pain. You live with someone who has Parkinson's 
disease, and he is unable to push you in a wheelchair. You require a scooter for use outside your home. It 
would be much easier for you to get down to the pool to do your exercises. The Plan denied your request. The 
Plan says the medical records show you are ambulatory within your home. You have knee pain, and you are 
using a 4-wheel walker around the house and going to the doctors office. You want the POV for community 
outings such as shopping and going to the pool. The medical necessity rules for coverage are not met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (POV) (K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (CPT code(s): 64493 X 2 and 
64494 X 2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the medical records show that the enrollee only achieved 60% pain relief after their first 
diagnostic facet joint procedure (MBB). 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the enrollee did not achieve 80% pain relief which is the criteria for a successful diagnostic block. 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the facet joint injections (CPT code(s): 64493 X 2 and 64494 X 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation to be provided by a surgeon at a tertiary 
care facility. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you want to see a doctor that is an 
expert and knows what they are doing as you consider your condition to be a rare disease in this country. The 
Plan denied your request. The Plan says a network provider can care for your medical problem. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the Plan has 
indicated in-network providers are available to prove the care that the enrollee requires. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service at this time. The requested service is not 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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the consultation to be provided by a surgeon at a tertiary care 
facility.
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 enrollee requires an intensive and coordinated 
interdisciplinary team approach to the delivery of rehabilitative care. The Plan denied your request. The Plan 
says admission to the IRF was denied as not meeting criteria, is not medically necessary, and a lower level of 
care might be appropriate. Skilled nursing facility level of care was offered. 
 
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 for atrial fibrillation and congestive heart failure. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. Medically necessary care can be provided in a different 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says if at any point in the treatment it is determined that the treatment becomes repetitive and 
does not require the unique skills of a therapist, the services are non-covered. 
 
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 the visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
The requested additional visits are not medically reasonable or necessary. Our physician reviewer found that 
the patient appears to have improved with therapy to the point of being able to manage walking in the 
community with no assistive device at times and she is independent with her home exercise program. After 
thirty-five physical therapy treatments, records do not support that the complexity of the patients conditions 
are such that the skills of a professional therapist are required to achieve further improvement in the patient's 
symptoms or functional status. Weakness and fatigue causing unsteadiness are her remaining challenges 
according to the latest therapy notes. Further utilization of the home exercise program appears appropriate at 
this point. Repetitive exercise does not require the expertise of a professional skilled physical therapist. There 
is no documentation that the unique skills of a professional therapist are required to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist or under the 
supervision of a therapist. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten additional physical therapy visits for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's care could be provided in 
an alternate setting such as a skilled nursing facility. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on May 11, 2022. 
 
You asked the Plan to pay for the office visit. You say that the service should be separately payable. The Plan 
denied your request. The Plan says that this is an incorrect procedure for an established patient. 
 
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. 
 
We looked at the file and the rules. The Plan did not provide a remittance, claim, or any other documentation to 
show that the enrollee received professional services from the physician or physician group within the previous 
3 years. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the office visit 
provided on May 11, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #3 (D2950) provided on May 24, 
2022. 
 
You asked the Plan to pay for core build up. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says core build up (D2950) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core build 
up on tooth #3 (D2950) provided on May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 18, 2022, to April 
21, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the Plan has inappropriately denied 
this claim. The Plan denied your request. The Plan says that there is no documentation that meets the criteria 
for inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from April 18, 2022, to April 21, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), as well as an 
expandable controller (E2377) with related electronic connections (E2311) and harness (E2313). 
 
You asked the Plan to pre-approve the power seat elevator and the expandable controller and related hardware. 
You say that it is felt that the requested items should be approved. The Plan denied your request. The Plan says 
all items were approved aside from E2300, E2377, E2311, and E2313. 
 
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 power seat elevator and the 
expandable controller and related hardware. Our reviewer says that the requested expandable controller is not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee suffers 
from amyotrophic lateral sclerosis (ALS) and is no longer able to use a walker. She is able to dress her upper 
body and toilet independently. The expandable control and associated electronics and controls are not 
medically necessary as the enrollee has sufficient upper body strength to manage standard controls. 
 
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 seat elevator and the expandable controller and related hardware have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature 
(E2300), as well as an expandable controller (E2377) with related electronic connections (E2311) and harness 
(E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on October 10, 
2021. 
 
You asked the Plan to pay for the initial hospital care. You say that the coding accurately reflects the 
appropriate level of service based on the Current Procedural Terminology (CPT) Evaluation and Management 
Guidelines. The Plan denied your request. The Plan says the documents do not support the level of care. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. 
 
 
 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 initial hospital care. Our reviewer found there was no 
medical decision making of high complexity. The review has determined that the documentation did not 
support procedure code initial hospital care (99223). 
 
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 initial hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for the initial hospital care (99223) provided on October 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95908, 95885) provided on June 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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 95908 is "Nerve conduction studies; 3-4 studies". The 
CPT Code Manual definition of code 95885 is "Needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(List separately in addition to code for primary procedure)". 
 
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 use of codes 95908 
and 95885 is not supported by the records provided. Our reviewer found that for CPT 95908, the procedure report describes "Pedicle Testing, which was reported with nerve conduction studies which measures amplitude 
and latency/velocity. Pedical screw stimulation is direct electrical current applied to each screw, and, nerve 
conduction study electrodes are placed directly over the nerve and electrical stimulation is applied.  Therefore, 
this procedure cannot be verified. Per CPT code description for code 95885, "done with nerve conduction, 
amplitude and latency/velocity". In this case, nerve conduction studies 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 the services (95908, 95885) provided on June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator with 
settings that could be delivered by BiPAP with AVAPS for this member with COPD is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found despite a diagnosis of chronic 
respiratory failure with chronic obstructive pulmonary disease, your pulmonary function testing is reported to 
show "nonspecific changes" with reduced lung volumes and reduced diffusion capacity and more of a 
restrictive pattern. Your chest computed tomography scan does not report findings suggestive of chronic 
obstructive pulmonary disease. No arterial blood gas studies are provided showing hypoxia or hypercapnia. 
Provided records document that the home ventilator is being requested for use with very low tidal volumes 
which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage 
Determination (L33800). "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zirabev. 
 
You asked the Plan to pre-approve Zirabev. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Zirabev. Our reviewer says that the 
services are medically necessary. Our physician reviewer found zirabev and tecentriq are approved first line for 
unresectable hepatocellular carcinoma (HCC) 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zirabev have been met. Therefore, we decided that the Plan has to pre-approve 
Zirabev.  
 
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.