Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the lateral sacral 
branches (64625). 
 
You asked the Plan to pre-approve a radiofrequency ablation. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says the requested service is 
experimental/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 a radiofrequency ablation. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested service is considered an experimental/investigational procedure because of 
the wide variation in efficacy reported in the literature. 
 
 
  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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a radiofrequency ablation procedure of the lateral sacral branches (64625).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot walk more than ten feet with 
moderate assistance and a front wheeled walker. You say previously the enrollee could walk with no assistance 
and no walker. The Plan denied your request. The Plan says per Medicare guidelines, the request for SNF 
services is not reasonable or necessary. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, there is 
inconsistent documentation that daily skilled services are required. Some records indicate sub-acute 
rehabilitation is needed and other notes indicate therapy two to three times per week is indicated. Based on the 
medical records provided, there is inadequate documentation that the enrollee requires the services on an 
inpatient basis in a skilled nursing facility (SNF) setting. No medical records have been provided with regard to 
the patient's medical needs. The physical therapy notes are inconsistent with regard to the intensity of treatment 
required by the patient. 
 
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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient/detoxification psychiatric care. 
 
You asked the Plan to pre-approve acute inpatient/detoxification psychiatric care. You say that the services at 
issue are medically necessary. 
 The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
   
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 acute inpatient/detoxification 
psychiatric care. Our reviewer says that the enrollee does not meet the criteria for acute inpatient/detoxification 
psychiatric care. Our physician reviewer found the enrollee did not require acute inpatient/detoxification 
psychiatric care as the enrollee was not a danger to himself or others and did not have any delusions, auditory 
or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It 
did not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve the enrollees condition or for the purpose of diagnosis. The enrollee was not showing any withdrawal 
symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient/detoxification psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient/detoxification psychiatric care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided to the enrollee from June 9, 2021, 
to June 12, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says there was no new documentation or clinical 
evidence presented to support an overturn of the initial audit findings. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, there was no clinical or laboratory evidence of sepsis. The review has determined that the 
documentation does not support diagnosis codes A41.51 (sepsis, due to escherichia coli) and A41.89 (other 
specified sepsis. The appropriate DRG is 690.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided to the enrollee from June 9, 2021, to June 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam radiation therapy (PBRT). 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
treatment does not offer clinical advantage over other forms of definitive radiation therapy. 
 
The Plan follows Medicare rules. Medicare rules say that proton beam therapy 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 coverage is limited to providers who have demonstrated experience in data collection and 
analysis with a history of publication on the peer-reviewed medical literature. This applies for this case. 
Specifically, for prostate cancer, the coverage criteria require physician documentation of the enrollees stage 
and other factors, which would include Gleason score, prostate specific antigen (PSA), and documentation of 
the range of therapy choices which is documented in the consultation note. As the criteria are met, the services 
are considered 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve proton beam radiation therapy (PBRT).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external catheter supplies to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve external catheter supplies. You say that you need catheters to help you with 
accidents. The Plan denied your request. The Plan says the needed supplies can be provided by an in-network 
supplier. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
external catheter supplies to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on September 16, 
2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you disagree with this coinsurance. 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for injections. This item/service falls 
within the Medicare Part B prescription drugs 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 coinsurance 
for injections provided on September 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 48 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 53 miles away from your 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found current evidence based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of this device for this enrollees medical condition. 
 
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 a Vertiflex Superion spacer.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94760 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 94760. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 94760 is considered bundled and 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 procedure code. 
 We find that procedure code 94760 has a status indicator of T on the Physician Fee Schedule. Code 94760 is 
only covered when there are no other services payable under the physician fee schedule billed on the same date 
by the same provider. Code 94760 was billed with code 93306 on the same date of service by the same 
provider. This means that procedure code 94760 is not payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code 94760 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 94760 billed for date of service August 17, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (83521) provided on July 21, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this procedure 
has been billed and allowed the maximum number of times allowed by our payment policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the billed services has been paid the maximum number of 
times by its payment policy. However, the Plan has not provided documentation showing that the maximum 
allowable for code 83521 has been exceeded. The Plan has not provided a Medicare rule or a Plan policy 
showing that this code is not payable in this case. Without supporting documentation, the Plan's denial cannot 
be substantiated. Therefore, we decided that the Plan has to pay for the lab services (83521) provided on July 
21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 15-21 classes (G0482) provided on 
August 25, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 15-21 classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says that only 9 drug classes were tested. 
 
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 G0482 is definitive drugs testing of 15-21 classes. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, we reviewed the records and 
confirmed that 15-21 classes of drugs were tested. Based on this information, we decided that Medicare rules 
for coverage of the definitive drug testing of 15-21 classes have been met. Therefore, we decided that the Plan 
has to pay for the definitive drug testing of 15-21 classes (G0482) provided on August 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar fusion with the Stabilink MIS interlaminar 
Spinal Fixation System (22612). 
 
You asked the Plan to pre-approve the lumbar fusion. You say that the enrollee has tried and failed multiple 
conservative and interventional treatment including spinous spacer devices and spinal cord stimulator. You say 
that the enrollee does not want to continue their medications. You also say that this is medically necessary. The 
Plan denied your request. The Plan says the requested service 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 the lumbar fusion. Our reviewer says 
that the requested lumbar fusion is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. The Food and Drug Administration 
(FDA) does not recommend this device as a stand-alone procedure. Additionally, the provided magnetic 
resonance imaging (MRI) is from 2019. The reviewer found there is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the reviewer found that the requested posterior lumbar fusion (CPT 22612) with the Stabilink MIS interlaminar 
Spinal Fixation System, in this case, 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 the lumbar fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lumbar fusion with the Stabilink MIS interlaminar Spinal Fixation System (22612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for (BRCA1 (BRCA1, DNA repair associated), BRCA2 
(BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence 
analysis and full duplication/deletion analysis (i.e., detection of large gene rearrangements)) (81162) provided 
August 18, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the enrollee's physician ordered genetic 
testing for the enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your 
request. The Plan says the enrollee has no cancer diagnosis therefore does not meet criteria per Medicare 
guidelines L39040. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for (BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary 
breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (i.e., 
detection of large gene rearrangements)) (81162) provided August 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
vertebrogenic low back pain. She presented with chronic low back pain. The pain is across the entire low back 
without radiation. She does report lower extremity weakness. There are multiple plausible pathologic sources 
of significant pain generation. The non-radiating midline back pain, the noted pain-aggravating factors 
(bending over and any movement), and the intact neurologic exam are all non-specific to any pathologic 
entities. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. 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 Intracept procedure.