Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that this imaging service is 
medically reasonable and necessary. The Plan denied your request. The Plan says that the criteria for coverage 
have not been met because the submitted records did not include a detailed history that shows this study is 
needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that the requested CT scan is medically reasonable and necessary. Our physician reviewer 
found this patient has been diagnosed with high grade bladder cancer in the past. He has a new left epididymal 
lesion.  Most recent cystoscopy revealed no tumor. Surveillance CT scan of the abdomen and pelvis has been 
requested but denied. In this case, this patient was unable to tolerate a full course of Bacillus Calmette-Guerin 
(BCG) immunotherapy and due to the prior history of bladder cancer a new left epididymal lesion is cause for 
concern.  Based upon the prior bladder cancer, new clinical finding and the incomplete immunotherapy a 
surveillance CT of the abdomen and pelvis is reasonable and should be approved. 
 
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 CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
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 drug testing services provided on February 10, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on November 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 
 
We looked at the file and Medicare rules. The file does not show that these services were either emergent or 
urgent. The file does not show that these services were pre-approved. Based on this information, we decided 
that Medicare rules for coverage of the physician services provided by an OON provider have not been met. 
Therefore, we decided that the Plan does not have to pay for the physician services provided on November 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second bilateral level of transforaminal epidural 
injections (64484) for the enrollee. 
 
You asked the Plan to pre-approve the second level. You say that this is medically necessary. The Plan denied 
your request. The Plan says they feel that the request at just one level is reasonable. 
 
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 second level. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this request exceeds the utilization criteria in the guidelines. Only one level bilaterally is 
considered medically reasonable and 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 second level have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a second bilateral level of transforaminal epidural injections (64484) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet Medicare guidelines for approval. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation that your condition requires position of the body in ways not feasible in an ordinary bed. There 
is no indication that your condition requires changes in body position or immediate changes in body 
position. Based on the medical records provided, there is no documentation that your condition requires special 
attachments that cannot be fixed and used on an ordinary bed. You do not meet Medicare criteria for medical 
necessity for the semi-electric hospital bed. 
 
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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an orthopedic surgeon. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any knee pain, or trials of medication, ice and heat packs, or 
activity modification for 6-8 weeks. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding the knees having been examined by her primary care 
physician or that initial conservative management has been attempted. The initial evaluation and management 
of these complaints are within the armamentarium of the primary care physician. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the requested referral to an orthopedic surgeon, 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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to an orthopedic surgeon.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided by on March 18, 2021. 
 
You asked the Plan to pay for the psychotherapy. You say that a taxonomy code is never on a claim. The Plan 
denied your request. The Plan says that the Claim Submission Policy requires the taxonomy code to be listed 
on the claim form in order for the claim to be processed and paid correctly. 
 
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 90834 is psychotherapy, 30 minutes with patient. 
 
We find that CPT code 90834 is supported in the medical record. Specifically, the provider's taxonomy is 
included in the NPI which is listed on the claim form, and the Plan has not given any other rationale or 
evidence to support a denial. Based on this information, we decided that Medicare rules for coverage of 
psychotherapy have been met. Therefore, we decided that the Plan has to pay for psychotherapy provided by on 
March 18, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that the patient needs additional therapy in order to 
return home. The Plan denied your request. The Plan says the patient does not require SNF admission and can 
be managed in a lower setting. 
 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the patient does not have skilled nursing 
needs.  The doctor says that the patient does require skilled therapy services, however it is not medically 
reasonable and necessary to provide skilled therapy services on a "daily basis" on an inpatient basis, in a skilled 
nursing facility setting. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that the current wheelchair is five years old and 
significantly worn. The Plan denied your request. The Plan says there is no documentation of a mobility 
limitation that significantly impairs the ability to participate in or more mobility-related activities of daily 
living. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of a personal mobility deficit that impairs participation in mobility-related activities of daily 
living.  The records report that he can "walk pretty well with a walker" in the home, but is requesting the power 
wheelchair for difficulty with ambulation "outside of the home." 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new power wheelchair for the enrollee.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, 
E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says left upper limb strength and function are adequate for the member to 
be able to control the power options using their own switches which are included in the allowance of these 
power options. 
 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 additional accessories. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52498). The patient does not require non-proportional input 
devices (e.g., sip and puff, head array, etc.). The patient does not require a separate display (i.e., for alternate 
control devices), other electronic devices (e.g., control of an augmentative speech device or computer through 
the chair's drive control), or an attendant control. The patient has 3 power options of tilt, recline, and power 
elevating leg rests but the patient does not need to control the power options through a joystick. The patient's 
left upper extremity strength and function support that the patient can control any power options through their 
own switches. 
 
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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (K0108, E2311, E2313, E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic computer-assisted navigation for total hip 
arthroplasty. 
 
You asked the Plan to pre-approve stereotactic computer-assisted navigation. You say that use of this technique 
means that the healing process is very fast and it's the best way and mechanism that your doctor has seen so far 
that has not had any issues after surgery and it means that you do not have to take heavy duty pills. The Plan 
denied your request. The Plan says it has approved the total hip arthroplasty but is denying stereotactic 
computer-assisted navigation because medical studies haven't proven that this is helpful for the treatment of 
your condition. 
 
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 stereotactic computer-assisted 
navigation. Our reviewer says that the requested service is not considered medically reasonable and necessary 
in this case. Our physician reviewer found computer navigation is not medically needed. The doctor says that it 
has not been shown to improve outcomes of the surgery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stereotactic computer-assisted navigation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve stereotactic computer-assisted navigation for total hip 
arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) (K0553) receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor 
system (K0554) purchased September 2, 2021. 
 
 You asked the Plan to pay for the CGM and supplies. You say that you would not dispense product without 
receiving the verification establishing coverage under the enrollee's plan and the approved authorization that 
was required. The Plan denied your request. The Plan says the enrollee does not meet all of the coverage 
criteria for the continuous glucose monitoring system and supplies. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that the enrollee has diabetes. The record indicates 
that the enrollee uses insulin once daily. The elements of the coverage criteria are not satisfied and the 
requested service is not 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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) 
receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554) purchased 
September 2, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee 
could receive care in another 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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for a stroke. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 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 the 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 pay for the surgery services provided on May 10, 2019. 
 
You asked the Plan to pay for the surgery services. You say that it was determined the service was not coded 
correctly after a review of the medical records. You say that the claim was sent to collections, and you are 
asking for the claim to be paid. The Plan denied your request. The Plan says your provider submitted this claim 
after timely filing limitations and no action is needed from you. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the surgery services was not filed until July 14, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. In addition, since the 
provider is a network provider you are not liable for these denied charges. Therefore, we decided that the Plan 
does not have to pay for the surgery services provided on May 10, 2019.