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

 
We decided that the Plan does not have to pay for the shoulder arthroscopy (29819) provided on May 21, 2021. 
 
You asked the Plan to pay for the shoulder arthroscopy (29819). You say that the doctor was unable to perform 
the procedure without the assistant surgeon. You say that the claim should be processed under the primary 
surgeon who has an in-network authorization status. The Plan denied your request. The Plan says the claim 
reprocessed to only deny CPT code 29819 as modifier AS is never allowed with a procedure that has an 
assigned indicator of 1. 
 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29819. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
shoulder arthroscopy (29819) have not been met. Therefore, we decided that the Plan does not have to pay for 
the shoulder arthroscopy (29819) provided on May 21, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 
You asked the Plan to pre-approve Lupron Depot. You say that the requested drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Lupron Depot. Our reviewer says that 
the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 
69-year-old man with a diagnosis of prostate cancer causing bilateral ureteral obstruction. The Plan requires a 
trial of Eligard (Leuprorelin acetate) before they will approve the requested drug. The case file does not contain 
documentation of trial and failure of Eligard (Leuprorelin acetate). The documentation does not support that 
Eligard (Leuprorelin acetate) would likely be less effective, and/or would likely have adverse effects for the 
enrollee 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 Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot.
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 you do not meet the 
guidelines for Inpatient Rehab Facility services as the clinical information indicates that your needs may be 
safely met in a skilled nursing facility 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve implant an intrathecal pump that delivers Fentanyl. 
 
You asked the Plan to pre-approve implant an intrathecal pump that delivers Fentanyl. You say that this is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the enrollee's 
diagnosis does not constitute a Food and Drug Administration approved indication. 
 
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 implant an intrathecal pump that 
delivers Fentanyl. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found this 69 year old woman is status post a lumbar spinal 
fusion and has chronic intractable pain. Evicore guidelines specifically addresses this issue: Clinical Guidelines 
CMM-210-Implantable intrathecal Drug Delivery Systems August 11, 2017 specifically lists failed back 
surgery syndrome as an indication. Fentanyl intrathecal is on the clinical practice guideline for intratthecal 
therapy. The Health Plan MD and Appeal specialist incorrectly applied an NCD. 
The request is 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 implant an intrathecal pump that delivers Fentanyl have been met. Therefore, 
we decided that the Plan has to pre-approve implant an intrathecal pump that delivers Fentanyl.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that additional transportation is 
necessary for you to attend appointments. The Plan denied your request. The Plan says the benefit for routine 
transportation has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way 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 20 additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
SNF 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on October 21, 2021. 
 
You asked the Plan to pay for the psychotherapy. You say that medical records are attached for processing the 
claim toward payment. The Plan denied your request. The Plan says that the provider must attempt to consult 
the attending or primary care physician about the services furnished. 
 
The Plan must follow Medicare rules. The rules say that when services are rendered by a Clinical Psychologist 
and the patient consents, you must attempt to consult their attending or primary care physician about the 
provided services. This does not apply if the physician referred the patient to the Clinical Psychologist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have been met. Specifically, the submitted claim includes a referring provider. 
Documentation of a consultation is not required when there is a referring physician. Therefore, we decided that 
the Plan has to pay for psychotherapy provided on October 21, 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the member needs rehabilitation services to 
recover properly. The Plan denied your request. The Plan says that the services the enrollee requires can safely 
be received at a different 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBO therapy or HBOT). 
 
You asked the Plan to pre-approve HBO therapy. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee does not have a covered indication for hyperbaric oxygen therapy. 
 
The Plan follows Medicare rules. Medicare rules state that HBO therapy is only covered for certain specified 
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 HBO therapy. Our reviewer says that 
the enrollee does not meet the Medicare criteria for HBO therapy. Our physician reviewer found the enrollee 
has diminished hearing loss in the right ear, and the plan is to save or at least improve the enrollee's acute left-
side hearing loss to a functional level. Hyperbaric oxygen therapy has been requested for this. The enrollee 
does not have an indication for which hyperbaric oxygen therapy is covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBO therapy or HBOT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography (75716) provided on March 19, 2021. 
 
You asked the Plan to pay for the angiography. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 75716 and 
37224. 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 75716 is angiography, extremity, bilateral, radiological 
supervision and interpretation. 
 
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 angiography. Our reviewer says that CPT code 75716 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report 
documents a bilateral extremity angiogram performed, in addition to revascularization of a unilateral femoral or 
popkiteal artery, which would include radiological supervision.  Therefore, This procedure would not be 
reported separately. 
 
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 angiography have not been met. Therefore, we decided that the Plan does 
not have to pay for the angiography (75716) provided on March 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine mileage. 
 
You asked the Plan to pre-approve the additional routine mileage. You say that you are in dire need of going to 
the provider that is further away. You also say that you have no way to travel there, and you cannot afford to 
pay a private transportation company in order to see the provider. The Plan denied your request. The Plan says 
your benefit only allows 50 miles one way. The Plan also says that you have exceeded your benefit mileage 
limit. 
 
 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 each one-way trip does not exceed 50 miles of driving 
distance.  
 
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. Therefore, we decided that the 
Plan does not have to pre-approve additional routine mileage.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering services provided to the enrollee on October 
18, 2021. 
 
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 the use of 3D-rendering with interpretation and reporting of computed tomography, magnetic 
resonance imaging, or other tomographic modality with image post-processing is not covered separately by 
Medicare as it is contained in the authorized radiologic 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found while there is documentation that 3D rendering was done on a separate workstation there is no 
explanation in the report as to the reason the 3D rendering was medically necessary and to what additional 
advantage it provided. Medicare rules require such documentation of justification.  
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 pay for 3D rendering services provided to the enrollee on October 18, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a cranioplasty for skull defect (62141) provided on August 6, 2021. 
 
You asked the Plan to pay for a cranioplasty for skull defect. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the code at issue is inclusive to 
another billed code. 
 
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.   
 
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 a cranioplasty for skull defect. Our reviewer 
says that the billed code meets criteria for reimbursement. Our physician reviewer found that the operative 
report describes a craniectomy of bone flap with tumor resection, due to erosion of prior craniotomy flap, 
which resulted in a cranioplasty for skull defect. 
 
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 cranioplasty for skull defect have been met. Therefore, we decided that the 
Plan has to pay for a cranioplasty for skull defect (62141) provided on August 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroplasty procedure (0201T). 
 
You asked the Plan to pre-approve a sacroplasty procedure. You say that no other procedure or alternative 
therapy available for the enrollee's condition. The Plan denied your request. The Plan says this procedure is not 
covered because it is not yet been found to be better than standard and accepted treatments. 
 
 
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 sacroplasty procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found sacroplasty is experimental for sacral insufficiency fractures. More research is 
needed before coverage can 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 sacroplasty procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroplasty procedure (0201T).