Persius/hicric huggingface dataset:
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 the enrollee 
needs to get to medical appointments. The Plan denied your request. The Plan says the enrollee's benefit only 
allows 12 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 
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 when the driving distance for a one-way trip is within 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 64.9 miles away from the enrollee's residence. The Plan only covers distances up to 50 miles. 
Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation 
(A0170).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient acute care and do not require a transfer to a long term acute care hospital. 
 
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 you are receiving appropriate care at the present setting. You do not require services 
at the LTACH that are not available at the acute care hospital where you are 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is not agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to a LTAC. The enrollee cannot adequately be managed in the current condition at a skilled nursing 
facility. The Plan denied your request. The Plan says based on Medicare guidelines, the long-term acute care 
hospital services you are requesting do not meet the requirements for approval. 
 
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 was admitted and had surgery for cancer of the pancreas with duodenum 
and liver involvement. The enrollee had problems with obstruction of the bile duct, jaundice and fluid in the 
abdomen. The oncologist has a treatment plan for outpatient palliative chemotherapy. There is no 
documentation provided indicating medical necessity for admission to a LTACH. 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 they are 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gocovri capsule. 
 
You asked the Plan to pre-approve Gocovri. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Gocovri 
capsule.  
 Benefits for Gocovri 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: 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 inpatient rehabilitation services will allow you to 
gain maximum potential. The Plan denied your request. The Plan says you could receive care in another setting 
such as a skilled nursing rehabilitation facility, if requested. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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: 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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet the requirements for approval. 
 
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 were admitted for lumbar spine surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. While you have 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. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program 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 IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a bunionectomy. 
 
You asked the Plan to pre-approve a bunionectomy. You say that your big toe is pointing to the left and the 
middle toe is being pushed against the other toes. You say that your balance is being affected and you may 
soon need a can. You say that you are in a lot of pain when using shoes and can only use specific types of 
shoes. The Plan denied your request. The Plan says that there is no evidence that non-operative therapy has 
been trialed. The Plan says that conservative care in the form of bunion splints, spacers, and wider shoes would 
be warranted. The Plan also says that there is no evidence that the enrollee's bunion is symptomatic as indicated 
by ulceration at the joint, difficulty walking, the inability to accommodate the deformity with wider shoes, the 
presence of an avulsion fracture, a grade III ligamentous sprain, or prior surgical malunion or 
nonunion. 
 
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 a bunionectomy. Our reviewer says that 
a bunionectomy is considered medically reasonable and necessary in this case. Our physician reviewer found it 
is well established in the medical documentation as well as the x-ray report that this patient is suffering with a 
severe bunion deformity left side with moderate degenerative joint disease to the first metacarpophalangeal 
joint (MPJ.) The patient advises that the bunion is causing pain and poor balance. The bunion is tender in most 
shoes. Both physical examination and x-rays reveal that this patient is suffering with a bunion deformity that is 
causing pain. It is within Medicare guidelines and standard of care that a bunion surgery be performed in order 
to correct the painful bunion deformity. 
 
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 bunionectomy have been met. Therefore, we decided that the Plan has to pre-
approve a bunionectomy.  
 
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 an implantable loop recorder (ILR).  
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ILR is covered when specific criteria 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of atrial 
fibrillation but there is no documentation to suggest a history of unexplained syncope, cryptogenic stroke, or 
any other apparent indication for an ILR. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitors (CGM) 
sensor and reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor and reader. You say that you do not agree 
with the denial. You need the requested machine, and it was prescribed by your provider. The Plan denied your 
request. The Plan says you do not meet coverage criteria for the requested items. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM sensor and reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 continuous glucose monitors (CGM) sensor and reader.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laparoscopy procedure (49320) billed for date of service 
November 11, 2021. 
 
You asked the Plan to pay for a laparoscopy. You say that you have provided records to support the services 
billed. The Plan denied your request. The Plan says the services billed are included in another billed code. 
 
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 49320 
is a column II code to column I code 49325 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a laparoscopy procedure (49320) billed for date of service November 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services coded 97598 and the service(s) 
provided in the office during regularly scheduled evening, weekend, or holiday office hours coded 99051 
provided on March 5, 2022. 
 
You asked the Plan to pay for the debridement services and the service(s) provided in the office during 
regularly scheduled evening, weekend, or holiday office hours. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are 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 97598 
is an add-on code and has not been billed with an appropriate primary procedure code. We find that procedure 
code 99051 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99051 is 
not separately payable. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the debridement services coded 97598 and the service(s) provided in the office during 
regularly scheduled evening, weekend, or holiday office hours coded 99051 provided on March 5, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the provider feels that the services 
should be covered because it will elevate the enrollee's fractured left femur or position change for self-care in a 
regular bed. The Plan denied your request. The Plan says that while the supplied documentation may support a 
fixed height or even a variable height hospital bed, it does not support the coverage criteria of the local 
coverage determination for a semi-electric hospital bed as the documentation does not indicate that the enrollee 
requires frequent and immediate need for a change in body position to qualify for a semi-electric hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is medically necessary. Our physician reviewer found there is documentation that 
the enrollee's condition requires position of the body in ways not feasible in an ordinary bed due to pain and 
mobility limitations due to the femur fracture and due to his sleep apnea and leg swelling. There is 
documentation that the enrollee requires frequent changes in body position. Provided records (medical progress 
noted dated and signed 08/01/2022) document the need for frequent changes in body position to alleviate pain, 
prevent aspiration and problems with respiration as well as generalized pain control. 
 
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 semi-electric hospital bed have been met. Therefore, we decided that the Plan 
has to pre-approve a semi-electric hospital bed (E0260).  
 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 pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that the member has failed nortriptyline, 
gabapentin pregabalin and capsaicin cream and has had limited quantities of narcotics, but these have provided 
limited relief and she needs to avoid narcotics given that she is a recovering addict. You say coverage for 
acupuncture is requested as this modality of treatment will help give her some relief for her constant pain. The 
Plan denied your request. The Plan says that based on Medicare guidelines, the acupuncture services do not 
meet the requirements for approval. The Plan says the records show a diagnosis of post herpetic neuralgia (pain after shingles infection). The record indicates the enrollee has pain in her right arm, hand, fingers and 
fingertips. There is no record of chronic lower back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements.  
 
We looked at the file, the Plans rules and Medicare rules. Based on this information, we decided that the rules 
for coverage of the acupuncture services have not been met. Specifically, the enrollee does not have chronic 
lower back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services billed for date of service September 30, 
2021. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the services 
rendered. The Plan denied your request. The Plan says the surgery date does not match the claim date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the codes billed are not supported in the medical records. The records show the services were 
provided on September 29, 2021. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the surgery 
services billed for date of service September 30, 2021.
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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet the requirements for 
approval. 
 
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 has a past medical history of a stroke with hemiparesis and is living at 
home. Medical problems are stable.  
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.