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

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can remain in the current acute care location until such time 
that no further acute level care is needed. 
 
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 patient appears to be stable and improving and should only require short-term 
additional acute care hospital services that can be safely completed at the current facility. The patient does not 
require services at the LTACH that are not already available at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be 
considered when treatment has completed. 
 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an Epidural Steroid Injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that a repeat injection is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The rules say that if a 
patient fails to respond well to the initial Epidural Steroid Injection (ESI), a repeat Epidural Steroid Injection 
(ESI) after 14 days can be performed using a different approach, level and/or medication, if appropriate, with 
the rationale and medical necessity for the second Epidural Steroid Injection (ESI) documented in the medical 
record. The requested procedure fulfills this part of the Medicare rules. Our physician reviewer found that your 
condition meets Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve an Epidural Steroid Injection (ESI).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopic synovectomy. 
 
You asked the Plan to pre-approve arthroscopic synovectomy. You say that the records provided support the 
need for the requested surgery. The Plan denied your request. The Plan says the requested procedure is not 
medically reasonable and 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 arthroscopic synovectomy. Our 
reviewer says that arthroscopic synovectomy is not considered medically reasonable and necessary in this case. 
Our physician reviewer found detailed documentation is not evident regarding magnetic resonance imaging 
(MRI) corroborating any synovitis in the left knee. There is a noted moderate knee joint effusion. The 
documentation does not detail when the fluid was withdrawn, and/or how long prior to the swelling having 
returned. Moreover, there is limited published, large-scale, long-term peer-reviewed literature that shows this 
overall request to be an effective and/or safe treatment for the clinically noted plica pathology. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthroscopic synovectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthroscopic synovectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis represented by code L1843, and a 
suspension sleeve represented by code L2397 
 
You asked the Plan to pre-approve codes L1843 and L2397. You say that the requested items are needed so 
that you can walk around like you used to. You say that you are currently sitting in a chair because you cannot 
walk. The Plan denied your request. The Plan says there is no documentation showing that the enrollee had a 
recent injury or surgery to the knee. The Plan says that there is no documentation showing that the enrollee has 
the ability to walk and an exam that shows his knee is unstable. 
 The Plan follows Medicare rules. Medicare rules say that knee orthoses and suspension sleeves are covered 
when 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 codes L1843 and L2397. Our reviewer 
says that the items in dispute are not medically necessary. Our physician reviewer found there is no evidence of 
a detailed properly performed musculoskeletal or neuromuscular examination or gait evaluation. There is no 
evidence of true instability on a physical exam. There is no pathological laxity with objective measurements of 
any laxity of the knee. There is no evidence of a recent surgery or injury to the knee. The documentation does 
not reveal a physician progress note indicating the patient is ambulatory. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L1843 and L2397 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee orthosis represented by code L1843, and a suspension sleeve represented 
by code L2397
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist 
(G0151) and direct skilled nursing services of a registered nurse (RN) (G0299). 
 
You asked the Plan to pre-approve services performed by a qualified physical therapist and direct skilled 
nursing services of a RN. The Plan denied your request. The Plan says there is no complex skilled nursing, and 
you are at your current baseline function status, as you have met your goals. The Plan also says that the home 
care services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services performed by a qualified 
physical therapist and direct skilled nursing services of a RN. Our reviewer says that the requested home health 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
you require additional skilled nursing services or skilled rehabilitation services to provide treatment that is 
medically necessary. Our reviewer found that you do not require additional skilled nursing or rehabilitation 
services to effectively provide treatment, care, and/or services in order to improve your condition, perform a 
maintenance program to maintain your condition and/or prevent deterioration. Our physician reviewer also 
found that you have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of services performed by a qualified physical therapist and direct skilled nursing 
services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve services 
performed by a qualified physical therapist (G0151) and direct skilled nursing services of a registered nurse 
(RN) (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair purchased on November 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
date of service at issue. Therefore, we decided that the Plan does not have to pay for the lift chair purchased on 
November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 10, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block for the right knee. 
 
You asked the Plan to pre-approve genicular nerve block for the right knee. The Plan denied your request. The 
Plan says genicular nerve block for right knee is experimental and investigational because their effectiveness 
for this indication has not been established by peer reviewed medical studies. 
 
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 genicular nerve block for the right knee. 
Our reviewer says that the requested genicular nerve block for the right knee is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that genicular nerve blocks and genicular 
nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee 
pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as 
a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for 
individuals who are not candidates for knee replacement surgery. The review has determined that the genicular 
nerve block is considered experimental/investigational in nature. The requested genicular nerve block 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 genicular nerve block for the right knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve block for the right knee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the requested drug is 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 Retacrit. Our reviewer says that 
Retacrit is not medically reasonable and necessary in this case. Our physician reviewer found it is not clear that 
the enrollee has anemia of chronic renal disease. The enrollee only has mild renal dysfunction and has low iron 
stores. ESA's can be used in isolated instances with low iron stores if it is documented that the enrollee has 
symptomatic anemia.  That has not been done 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower spine without contrast (72148). 
 
You asked the Plan to pre-approve an MRI of the lower spine without contrast. The Plan denied your request. 
The Plan says an MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lower spine without 
contrast. Our reviewer says that an MRI is not medically reasonable and necessary. Our physician reviewer 
found that no detailed neurological exam is in the records. Home health physical therapy (PT) has been ordered 
but there is no documentation of compliance, progress etc. Lumbar x-rays showed no fracture. No red flag has 
been presented to provide justification of MRI without completing the already prescribed PT. 
 
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 MRI of the lower spine without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an MRI of the lower spine without contrast (72148).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Symbicort. 
 
You asked the Plan to pre-approve Symbicort. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication would be covered under the enrollee's prescription drug plan. 
 
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 Symbicort.  
 
Benefits for Symbicort 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 replacement of a spinal cord stimulator battery/a new 
spinal cord stimulator pulse generator. 
 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation to support medical necessity. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the request is not just for a battery change. The request is also for a new pulse generator that is 
magnetic resonance imaging (MRI)-compatible. The neurologist has to clearly justify the diagnosis of multiple 
sclerosis, and why you are not on any medications. 
 
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 procedures have not been met.  Therefore, we decided that the Plan does not have to pre-approve replacement of a spinal cord stimulator 
battery/a new spinal cord stimulator pulse generator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, an unspecified vitamin assay, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 70450 and 99053 billed for date of service 
November 29, 2021. 
 
You asked the Plan to pay for procedure codes 70450 and 99053. You say that the patient had multiple exams 
on this date of service. The Plan denied your request. The Plan says payment for procedure code 70450 is 
bundled into payment for code 70496.  The Plan also says that procedure code 99053 is not separately payable. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit.  
 
In addition, procedure code 99053 has a status indicator of B on the Medicare Physician Fee Schedule 
Database.  Medicare rules say that for codes that have a status indicator of B, payment is always bundled into 
payment for other services and separate payment is never made. 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 
70450 and 99053 billed for date of service November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 18, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on November 18, 2021.