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

 
We decided that the Plan has to pre-approve a Lower Extremity w/o Dye Computed tomography (CT) 73700, 
lower extremity; without contrast material. 
 
You asked the Plan to pre-approve a Computed tomography (CT) 73700. You say that the enrollee has concern 
related to a joint problem that occurs when the cushion between your joints breaks down (arthritis), the 
computed tomography (CT) is for surgical planning. The Plan denied your request. The Plan cannot approve 
this request, the study must be requested as a pre-operative study for a surgery to replace your joint that has 
been approved or does not have to be approved. 
 
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 Computed tomography (CT) 73700. 
Our reviewer says that you need this medical item. Our physician reviewer found the review indicates that the 
computed tomography scan is being requested for the MAKO protocol in association with the planned left knee 
replacement, the review has determined that the requested scan 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 a Computed tomography (CT) 73700 have been met. Therefore, we decided that 
the Plan has to pre-approve a Lower Extremity w/o Dye Computed tomography (CT) 73700, lower extremity; 
without contrast material.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 18, 2020, to 
November 19, 2020. 
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says this claim was not filed timely. 
 
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 home health services was not filed until October 21, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for home health services provided on November 18, 2020, to 
November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography) (64625). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you believe this service is medically 
necessary and is appealing the denial. The Plan denied your request. The Plan says the requested service is not 
medically necessary. This treatment has not been proven as effective as standard treatment of SI joint pain. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (i.e., 
fluoroscopy or computed tomography) (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service April 21, 
2021. 
 
You asked the Plan to pay for procedure code 99072. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99072 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service April 21, 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 needs IRF care to achieve a safe and 
sustainable discharge. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat Zilretta injection. 
 
You asked the Plan to pre-approve a repeat Zilretta injection. You say that you would like the Zilretta shot to 
be approved because you received it in January, and it worked great. The Plan denied your request. The Plan 
says Zilretta is not recommended for repeated administration and criteria for medical necessity have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 repeat Zilretta injection. Our reviewer 
says that the criteria for coverage have not been met Our physician reviewer found the efficacy and safety of 
repeat administration of Zilretta for osteoarthritis of the knee have not been demonstrated. 
 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 repeat Zilretta injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat Zilretta injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a whole-body bone scan (code 78306) and a CT of the 
pelvis with contrast (code 72193). 
 
You asked the Plan to pre-approve a whole-body bone scan and a CT of the pelvis with contrast. You say that 
the bone scan and the CT of the pelvis with contrast have been ordered to rule out metastatic disease and to 
assist with treatment planning. You say if the imaging studies are negative for metastatic disease, the member 
will have a prostatectomy and if the imaging studies are positive for metastatic disease the member will be 
referred to oncology for systemic treatment. The Plan denied your request. The Plan says the requested 
whole- body bone scan and CT of the pelvis with contrast 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 a whole-body bone scan and a CT of the pelvis with contrast. Our reviewer says that the requested whole-body bone scan and a CT of the pelvis 
with contrast are not considered medically reasonable and necessary in this case. Our physician reviewer found 
that advance imaging is not indicated for men with clinically localized, favorable intermediate risk prostate 
cancer. The current American Urological Association (AUA) guidelines state: Clinicians should not routinely 
perform abdominal pelvic computed tomography (CT) scan or bone scan in asymptomatic patients with low or 
intermediate-risk prostate cancer. Clinicians should obtain a bone scan and either pelvic multi-parametric 
magnetic resonance imaging or CT scan for patients with high-risk prostate cancer. (Strong Recommendation; 
Evidence Level: Grade B). In patients with prostate cancer at high risk for metastatic disease with negative 
conventional imaging, clinicians may obtain molecular imaging to evaluate for metastases. 
 
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 whole-body bone scan and a CT of the pelvis with contrast have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a whole-body bone scan (code 78306) and a 
CT of the pelvis with contrast (code 72193).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement parts for a total electric hospital bed 
(E1399). 
 
You asked the Plan to pre-approve replacement parts. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the request is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. The request is not a covered benefit. Total electric hospital beds are not covered and 
repairs to them are not covered. Therefore, we decided that the Plan does not have to pre-approve replacement 
parts for a total electric hospital bed (E1399).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation code A0425-HR billed for date of 
service July 9, 2022. 
 
You asked the Plan to pay for the billed code. You say that these are separate ambulance trips. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
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 shows that the ambulance transportation from hospital to 
residence was reimbursed by the Plan on September 8, 2022. A comparison of the two claim lines shows these 
are duplicates. There is no evidence presented to support that the billed transportation services from hospital to 
residence were provided twice on the same date. Based on this information, we decided that the Medicare rules 
for the billed code have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
transportation code A0425-HR billed for date of service July 9, 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. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees 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 seroma of the groin. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. 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 pay for the anesthesia services provided on November 17, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. 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 December 6, 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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on November 17, 
2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you are unable to drive, and have no family 
or friends to drive you. You also say that you need transportation, or you are going to die a slow death. The 
Plan denied your request. The Plan says that your benefit only allows 50 miles, and this request exceeds your 
benefit limit. The Plan also says this request is not covered by your health plan. 
 
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 records do not support that the location you wish to be transported is more 
than 50 miles of driving distance. The Plan has not given us the specific information needed to determine that 
the requested destination is beyond 50 miles. Specifically, there was not a provider's name or address showing 
where you would like to be transported to. This means that the Plan has not provided a valid reason for denying 
approval of additional mileage. It is the burden of the Plan to substantiate their denial with evidence. Therefore, 
we decided that the Plan has to pre-approve additional mileage.  
 
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: Favorable

 
We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) services. 
 
You asked the Plan to pre-approve IMRT services. You say that the medical documentation provided supports 
the need for IMRT. The Plan denied your request. The Plan says that there is no direct medical evidence to 
show that the requested type of radiation treatment is more effective than other kinds of radiation to treat the 
enrollee's cancer. 
 
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 IMRT services. Our reviewer says that 
IMRT services are considered medically reasonable and necessary in this case. Our physician reviewer found 
IMRT is not experimental, but rather a useful tool available to radiation oncologists to potentially reduce 
toxicity and improve the lung and skin dose distributions. In light of the dosimetric improvement with IMRT in 
this patient, as well as The American Society for Radiation Oncology's (ASTROs) most recent update of its 
Choosing Wisely list, our physician reviewer found that IMRT would be furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT services have been met. Therefore, we decided that the Plan has to pre-
approve intensity modulated radiation therapy (IMRT) services.  
 
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 a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee has hypercapnic and hypoxic 
respiratory failure, requiring bi-level positive airway pressure (BiPAP) dependence 24 hours a day, 7 days a 
week, inpatient and outpatient. The Plan denied your request. The Plan says the ventilator would be set in 
average volume-assured pressure support (AVAPS) mode with Auto- expiratory positive airway pressure 
(EPAP), which could be delivered by bi-level positive airway pressure (BiPAP) at home. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 ventilator. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically 
necessary. The enrollee was recently hospitalized with pneumonia and acute exacerbation of chronic 
obstructive pulmonary disease (COPD.) There are also diagnoses of severe obesity, obesity hypoventilation 
syndrome, heart failure with preserved ejection fraction (HFpEF), and pulmonary hypertension. There is 
reportedly a history of carbon dioxide (CO2) retention during previous hospitalizations. Blood gas results are 
not provided. There are no pulmonary function test results to document airways obstruction or COPD severity. 
There is no documentation of failure of bi-level positive airway pressure (BiPAP) as an outpatient. If this 
enrollee does have chronic CO2 retention, may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) during sleep. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 enrollee's records 
do not show that your rehabilitation needs are complex or that you need an intensive team for your care, 
services needed can be provided safely in other settings, at a skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 
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. 
 
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.