Persius/hicric huggingface dataset:
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 a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says a LTACH admission is not medically 
necessary. 
 
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 that the enrollee appears to be more stable and improving but requires short-term 
additional acute care hospital services that can be safely completed at the current facility until she is more 
stable and appropriate for a lower level of care.  The enrollee does not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. 
Completion of treatment at the current facility is 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee continues to use and 
benefit from nocturnal oxygen. The Plan denied your request. The Plan says blood gas testing was not 
performed. 
 
The Plan must follow Medicare rules. The rules say that oxygen and oxygen equipment is only covered under 
certain medical 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 requested services. Our physician 
reviewer found that the enrollee has a past medical history of bronchiectasis, aspiration pneumonia and 
nocturnal hypoxia. An oxygen concentrator has been requested. The provided records do not document an 
arterial oxygen level at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent. The 
provided records document a resting oxygen level of 97% on room air and an oxygen level of 98% on room air 
with ambulation of 200 meters. There is no documentation that supplemental oxygen is still medically 
necessary and reasonable in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on September 13, 
2021, billed with principal diagnosis code Z80.0. 
 You asked the Plan to pay for the outpatient hospital services as billed. You say that this should be paid. The 
Plan denied your request. The Plan says this was billed with an unacceptable principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the I/OCE imposes coding edits for outpatient 
hospital claims. Many of these edits will cause the claim to return to provider to cure the error. 
 
We looked at the file and Medicare rules. The billed principal diagnosis code of Z80.0 is listed as unacceptable 
in the MCE. There is no flag indicating it is allowed by OPPS. Based on this information, we decided that 
Medicare rules for coverage of the outpatient hospital services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital services provided on September 13, 2021, 
billed with principal diagnosis code Z80.0.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasopharyngoscopy surgical dilation eustachian tube 
bilateral. 
 
You asked the Plan to pre-approve nasopharyngoscopy surgical dilation eustachian tube bilateral. You say that 
you have had the placement of tubes over many years, and it has always been a temporary fix. You say that you 
have tried multiple medications. You say that your only other option is to have your ear removed, which would 
put you out of work for two weeks and would be a detriment to your living. You say that the requested balloon 
procedure would have a 24-hour recovery time. The Plan denied your request. The Plan says the requested 
procedure is considered 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 nasopharyngoscopy surgical dilation 
eustachian tube bilateral. Our reviewer says that nasopharyngoscopy surgical dilation eustachian tube bilateral 
is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee 
has diagnoses that include eustachian tube dysfunction, chronic otitis media, and otorrhea. There is insufficient 
evidence to recommend nasopharyngoscopy with surgical dilation of the eustachian tubes for the treatment of 
eustachian tube dysfunction, chronic otitis media, and otorrhea. The documentation does not support that the procedure is at least as beneficial as an existing and available medically appropriate alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nasopharyngoscopy surgical dilation eustachian tube bilateral have not been 
met. Therefore, we decided that the Plan does not have to pre-approve nasopharyngoscopy surgical dilation 
eustachian tube bilateral.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667). 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for a 
pneumatic compression device coded E0652 have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression devices 
(E0652, E0667).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation (A0100) beyond the Plan's 24-trip 
limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
dialysis appointments. The Plan denied your request. The Plan says you have exhausted your transportation 
benefit. 
 
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 a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve routine transportation (A0100) beyond the Plan's 24-trip 
limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you have back problems and can barely 
pull yourself out of your chair. The Plan denied your request. The Plan says rules for coverage for a seat lift 
mechanism have not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We looked at the file and Medicare rules. The case record does not support that you are completely incapable 
of standing up from a regular armchair or any chair in your home. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
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 are requesting IRF for the enrollee because the 
enrollee is at risk for readmission to hospital, declined skilled nursing facility level, needs daily oversight for 
shortness of breath, heart failure, and debility. The Plan denied your request. The Plan says based upon the 
enrollee's current level of function, the enrollee does not require an intensive, complex, multidisciplinary 
approach to daily therapy. The medical records do not support the ability to tolerate an intensive rehabilitation 
therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. Criteria for 
admission to the Acute Inpatient Rehabilitation setting have not been met. The enrollee's ongoing skilled 
therapy and nursing needs can be provided at a lower level of care such as at a Skilled Nursing Facility, on an 
intermittent basis at home with home health care, or in a long-term care setting. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for congestive heart failure. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are requesting this denial be 
overturned and the procedure authorized. Significant clinical and diagnostic patient specific data in support of 
medical necessity is included in the attachments. The Plan denied your request. The Plan says the clinical value 
and effectiveness of the Intracept procedure in the setting of chronic low back pain have not been 
demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare ules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the outpatient Intracept procedure (64628, 64629).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for MRI, breast, without and with contrast material(s), including computer-
aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when 
performed; bilateral (CPT code 77049) provided on January 18, 2022. 
 
You asked the Plan to pay for the MRI. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the service is considered to be experimental or investigational. 
 
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 pay for the MRI. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found a post lumpectomy MRI six (6) months later is perfectly appropriate for invasive lobular 
cancer. This patient also has had prior benign breast biopsies on the left. Invasive lobular carcinoma is often 
multifocal and bilateral. There is nothing experimental about the procedure in this case. Also note on the 
patient's prior MRI there was an equivocal lymph node with suspicious enhancement characteristics providing 
yet another valid indication for the procedure. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pay for 
MRI, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion 
detection, characterization and pharmacokinetic analysis), when performed; bilateral (CPT code 77049) 
provided on January 18, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for IRF admission and services. 
 
You asked the Plan to pay for IRF care. You say that you would like to appeal for the IRF services that were 
denied. The Plan denied your request. The Plan says the records do not show that the enrollee is able to take 
part in 3 hours of therapy a day at least 5 days a week, nor does the enrollee need to be seen by a rehab doctor 
three times per week, nor does the enrollee need an intensive team for care. The services the enrollee needs can 
be provided safely in other settings, for example, 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 pay for 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient 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 pay for IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
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 a third RFA session is not covered. 
 
The Plan must follow Medicare rules. The rules say that for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. The file shows that you previously had RFA on January 28, 2022 and 
March 3, 2022. A third session is not covered. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82947, 84450, 84550, 
and 82247) provided on February 2, 2022, by out-of-network providers. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says this provider is out-of-network, the services were not referred by a network 
provider, and the services were 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82947, 
84450, 84550, and 82247) provided on February 2, 2022, by out-of-network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 You asked the Plan to pre-approve epidural steroid injection. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because there is no indication to support a second injection after a failed first injection. 
 
The Plan follows Medicare rules. Medicare rules state that repeat epidural injections after a failed initial 
injection are only covered under certain circumstances.  
 
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 epidural steroid injection. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested repeat epidural. Our physician 
reviewer found a repeat injection is indicated when the first injection directly and significantly provided 
improvement of the condition being treated. There is no indication in the progress notes or in the request itself 
for a different approach, a new type or greater amount of anti-inflammatory agent, or any rationale given for 
the medical necessity of a second injection after a failed first injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on January 4, 2022. 
 
You asked the Plan to pay for the CT scan (70450). You say that the claim denied as a duplicate in error and 
the claim should be reprocessed for reimbursement according to the contract. The Plan denied your request. 
The Plan says an appropriate modifier was not billed with this code edit. 
  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. 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 CT scan (70450) provided on January 4, 2022.