Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PBRT. 
 
You asked the Plan to pre-approve the PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies have not shown that PBRT is better than other treatments for this type of 
cancer. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
PBRT for prostate cancer is superior, inferior or equivalent to external beam radiation therapy, intensity-
modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. The most recent 
American Urological Association (AUA) guidelines state that PBRT offers no clinical advantage over other 
forms of definitive treatment. 
 
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 PBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PBRT.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerve. 
 
You asked the Plan to pre-approve RFA of the genicular nerve. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered 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 RFA of the genicular nerve. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the role of RFA of the genicular nerves after total knee replacement is still 
being evaluated and it is considered experimental/investigational at this time. Therefore, the request is deemed 
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 RFA of the genicular nerve have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerve.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear medicine bone scan. 
 
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 has polycythemia and a 
total body bone scan is reasonable. The Plan has approved a total body radionuclide bone scan described by 
code 78012. The requested scan described by code 78306 is 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 a nuclear medicine bone scan.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on May 17, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
documentation does not support the billed date of service. 
 
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. 
 
We looked at the file and the rules. The Plan has not proven that one of the exceptions in the Medicare rules 
have not been met. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the laboratory services provided on May 17, 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: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 14, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
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. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 15, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services provided on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot come home yet due to aspiration, 
disorientation, high sodium, fluid in their lungs, and being on oxygen. The Plan denied your request. The Plan 
says the IRF services you are requesting 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also found that 
there is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 2, 2022, 
to April 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient stay was medically 
necessary. The Plan denied your request. The Plan says this could have been an observation stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient is a 57-year-old female who presented to the hospital with leg swelling, 
abdominal swelling, and tightness in chest and shortness of breath. She was found to have hemoglobin of 7.8, 
had high blood pressure (174/70) but was 95% on room air and was treated with 1 unit of packed red blood 
cells and Lasix with symptom improvement. Her vitals remained stable at the time of admission. There was no 
indication that the patient would have required hospital services that would have likely crossed 2 midnights. 
Observation level of care would have sufficed for this patient at that time based on the provided 
documentation.  
 
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 hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 2, 2022, to April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the criteria for 
admission to the Acute Inpatient Rehabilitation setting have not been met. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also found that 
there is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has chronic venous insufficiency. The 
Plan denied your request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found not all criteria have been met. Additionally, the documentation does not support the medical necessity of 
the procedure(s) in question. 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 services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sclerotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiofrequency ablation, nerves innervating the sacroiliac 
joint, with image guidance provided on October 26, 2021. 
 
You asked the Plan to pay for radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance. You say that the services were medically necessary. The Plan denied your request. The Plan says 
radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of radiofrequency ablation, nerves 
innervating the sacroiliac joint, with image guidance provided on October 26, 2021 have been met. The file 
does not contain the required medical records. Therefore, we decided that the Plan does not have to pay for 
radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance provided on 
October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (CPT code 64624). 
 
You asked the Plan to pre-approve the service. You say that the pain is constant and excruciating. The Plan 
denied your request. The Plan says there is not enough medical proof that shows the safety and/or success of 
right knee genicular injection when used for this reason. The Plan states it falls under the class of experimental 
and unproven and is not covered by your Health Plan. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
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 requested right knee genicular injection, 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, 
when performed (CPT code 64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the services cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   The medical records provided do not show that the services billed with the -59 modifier were distinct 
procedural services. Based on this information, we decided that Medicare rules for coverage of services billed 
with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a portable gaseous 
oxygen system (E0431). 
 
You asked the Plan to pre-approve an oxygen concentrator and a portable gaseous oxygen system. You say that 
you are homebound and not able to do your daily functions due to the lack of oxygen. You also say you have 
heart failure, atrial fibrillation, high blood pressure and you are having trouble sleeping. The Plan denied your 
request. The Plan says you do not meet coverage of supplemental oxygen. The requesting provider also agrees 
you do not meet coverage for supplemental oxygen at this time based on the current information. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an oxygen concentrator and a portable 
gaseous oxygen system Our reviewer says that the service is not medically necessary. Our physician reviewer 
found on 3/31/22 your oxygen saturation was 98% on room air. The Room Air Exercise Desaturation Study (6-
minute walk) on 4/26/22 demonstrated a 98% SPO2 on room air. The study was normal. Coverage criteria for 
home oxygen therapy has not been met. The documentation in the case file does not support that supplemental 
oxygen is medically reasonable and necessary for you 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 an oxygen concentrator and a portable gaseous oxygen system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a 
portable gaseous oxygen system (E0431).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 13, 2022, to 
April 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the 
three Q codes (Q5001, Q5002, and Q5009). 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with one of the 
required Q codes. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from April 13, 2022, to April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport chair (E1038) provided to the enrollee on March 
15, 2022. 
 
You asked the Plan to pay for the chair. You say that this should be paid for. The Plan denied your request. The 
Plan says this was purchased, not rented. 
 
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 E0138 is "Transport chair, adult size, patient weight 
capacity up to and including 300 pounds." 
 
We find that CPT code E0138 is not supported in the medical record. Specifically, this item was purchased, 
when it is only meant to be rented. Based on this information, we decided that Medicare rules for coverage of 
the chair have not been met. Therefore, we decided that the Plan does not have to pay for a transport chair 
(E1038) provided to the enrollee on March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure is medically necessary and 
supported by strong science. The Plan denied your request. The Plan says there is insufficient evidence for the 
efficacy of this procedure. 
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding Modic changes at all of the requested 
levels for the Intracept procedure. Additionally, there are multiple plausible pathologic sources of significant 
pain generation. Overall, documentation is lacking regarding reasonably detailed evidence findings supporting 
of the spinal vertebral bodies as being the overwhelming primary generators of the enrollee's chronic pain. 
There is no compelling rationale or extenuating circumstance noted to support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intraosseous ablation of the basivertebral nerve (Intracept procedure).