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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are currently not steady enough to get up on 
your own. You need guidance to be able to walk and need an intense therapy program to progress in your 
recovery. The Plan denied your request. The Plan says the requested IRF admission is not medically necessary.  
  
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you live alone and are very unstable walking 
around. You say that you need more rehabilitation. The Plan denied your request. The Plan says the clinical 
information does not show that the enrollee meets the criteria for coverage of SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documentation that the enrollee requires skilled nursing services. Records 
do not document the need for intravenous medications, new tube feeding, ostomy care, daily complex wound 
care, or respiratory care. While the enrollee does require skilled therapy services, they are not required on a 
daily basis. The enrollee is walking household distances independently with a rolling walker and is independent 
for transfers. The provided records do not document a significant decline in the enrollee's functional status 
compared to her recent baseline to necessitate daily inpatient skilled therapy services. There is no 
documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Records support that services in the home or an assisted living facility with home health care or in a 
long-term care facility on a part time basis are appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection device for a power mobility device. 
 
You asked the Plan to pre-approve electronic connection device. You say that the enrollee qualifies based on 
their condition. The Plan denied your request. The Plan says that this is not medically necessary. 
 
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 electronic connection device. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the electronic connection is necessary to operate the Group 3 power wheelchair 
base and the power tilt/recline and power elevating leg rests via a joystick. The enrollee has a cervical spinal 
cord injury and does not have the manual dexterity to operate the power wheelchair options with their own 
switches. This is more complex than feeding with an assistive device or utilizing tenodesis to facilitate 
movement of the hand and wrist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic connection device have been met. Therefore, we decided that the Plan 
has to pre-approve an electronic connection device for a power mobility device.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on March 04, 2022. 
 
You asked the Plan to pay for the office visit (99213). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99213) 
provided on March 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (the 
MILD procedure). 
 
You asked the Plan to pre-approve MILD procedure. You say that the enrollee is eligible for coverage and this 
is medically necessary. The Plan denied your request. The Plan says the enrollee has already had a MILD 
procedure within the past 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers the MILD procedure through 
CED for beneficiaries with lumbar spinal stenosis who are enrolled in an approved clinical study.  
 
We looked at the file and Medicare rules. You have requested enrollment in trial NCT03072927, which is a 
Medicare approved CED study; however, this study is not currently recruiting new participants. Therefore, the 
enrollee cannot receive coverage for the MILD procedure through this CED study at this time. Based on this 
information, we decided that Medicare rules for coverage of MILD procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (the 
MILD procedure).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on October 17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no immediate significant treat to life, or a hospital admission. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical decision making was 
not of high complexity. The enrollees illness/condition did not pose an immediate threat to life/limb. As such, 
the billing of CPT 99285 is not supported. 
 
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 emergency department services (procedure code 99285) rendered on October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 and 93010 billed for date of service 
June 13, 2022. 
 
You asked the Plan to pay for procedure codes 99285 and 93010. You say that these services were performed 
multiple times on the same day by different providers. The Plan denied your request. The Plan says this claim 
is a duplicate of a previously paid claim and was correctly denied. In addition, the number of units of 99285 
billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. Medicare 
rules also say that submitted claims in which the unit of service exceeds the MUE value cannot be paid when 
the MAI value is 3, unless there is evidence justifying the excess units. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 18, 2022. Comparison of the two claims shows these are exact duplicates, with 
the exception of code 99285 which was billed with a modifier. The rendering providers on both claims are the 
same. There is no evidence presented to support that the billed items/services were provided twice on the same 
date or that it was medically necessary to do so. In addition, the MUE for CPT code 99285 is 1. The MAI value 
for this code is 3. You billed 3 units of this code, exceeding the MUE. You did not provide all the required 
evidence showing that the excess units were actually provided, were correctly coded, and were medically 
necessary. Based on this information, we decided that the Medicare rules for procedure codes 99285 and 93010 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99285 and 
93010 billed for date of service June 13, 2022.
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 need intense therapy in order to get back to your 
prior level of function. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 fractions if intensity-modulated/image-guided 
radiation therapy (IMRT/IGRT). 
 
You asked the Plan to pre-approve IMRT/IGRT. You say that this is medically necessary to shape the dose to 
the targeted region while avoiding normal surrounding structure. The Plan denied your request. The Plan says 
this is not medically 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 IMRT/IGRT. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in an individual undergoing bladder preservation the use of 55 Grey in 20 fractions or 30 to 37 
fractions using 3-dimensional conformal radiation therapy is considered medically necessary. There is no data showing that image-guided radiation therapy is more beneficial than 3-dimensional conformal radiation 
therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT/IGRT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 20 fractions if intensity-modulated/image-guided radiation therapy (IMRT/IGRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) of the brain. 
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the service is not 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks and genicular nerve radiofrequency ablation.

You asked the Plan to pre-approve genicular nerve blocks and genicular nerve radiofrequency ablation. You say that the requested genicular nerve blocks and genicular nerve radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve blocks and genicular nerve radiofrequency ablation is not medically 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 genicular nerve blocks and genicular nerve radiofrequency ablation. Our reviewer says that the requested genicular nerve blocks and genicular nerve radiofrequency ablation is not medically necessary. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency 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 blocks and genicular nerve radiofrequency ablation are considered experimental/investigational in nature. The requested genicular nerve blocks and genicular nerve radiofrequency ablation are not reasonable and 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 genicular nerve blocks and genicular nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks and genicular nerve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the programming of dual lead implantable defibrillator system (93238) provided on October 17, 2022.

You asked the Plan to waive the cost share for the specialist service. You say that you have never had to pay a copayment for this service. The Plan denied your request. The Plan says this cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $35 copayment for the outpatient service. This service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the programming of dual lead implantable defibrillator system (93238) provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated seat cushion for a power wheelchair. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a custom fabricated seat cushion 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 medically necessary. Our physician reviewer found that the records support that you have a 
significant pressure injury to the sacral region that would necessitate the use of a custom fabricated seat 
cushion. The criteria for coverage are met and the custom fabricated seat cushion is reasonable and medically 
necessary at this time. 
 
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 a custom fabricated seat cushion for a power wheelchair.  
 
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 pre-approve the mileage limit extension.

You asked the Plan to pre-approve the mileage limit extension. You say that you need to have a colonoscopy and need to use the transportation benefit in order to go to the appointment. The Plan denied your request. The Plan says the service is not a covered 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 Plan's coverage rules apply in this case. The Plan covers up to 30 one-way rides per year to other health care related locations 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 the mileage limit extension.