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

 
We decided that the Plan does not have to pre-approve peripheral nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request, in particular for the hip, is considered investigational and not a covered 
benefit. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental and investigational procedure. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve peripheral nerve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology consultation for Mohs surgery to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON dermatology surgical consultation. You say that you were seen by 
network providers, and you feel that they have given you incorrect recommendations. You state that one of the 
providers offered to do the surgery, but would not close the wound which you feel is not acceptable. You have 
met with the requested OON physician before and feel that he would be the best choice at this time. The Plan 
denied your request. The Plan says the necessary services are available from network dermatologists. There is 
no medical reason that only the requested OON provider could furnish the care you require. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dermatology consultation for Mohs surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee (L5848, L5845, L5828, L5856, 
L5850), VASS, shock reducing pylon, and K4 advanced frame. 
 
You asked the Plan to pre-approve a microprocessor knee (L5848, L5845, L5828, L5856, L5850), VASS, 
shock reducing pylon, and K4 advanced frame. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the type of knee for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. 
 
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 microprocessor knee (L5848, L5845, 
L5828, L5856, L5850), VASS, shock reducing pylon, and K4 advanced frame.. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the K3 microprocessor knee is a Rheo XC 
(coded L5848 + L5845 + L5828 + L5856 +L5850). The Rheo XC and accessory components are not medically 
necessary as the physician documentation does not support that the enrollee requires a Rheo XC 
microprocessor knee over a mechanical knee. Additionally, a review of this microprocessor knee indicates that 
this knee has cycling and running features which exceed the enrollee's medical need. 
 
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 microprocessor knee (L5848, L5845, L5828, L5856, L5850), VASS, shock 
reducing pylon, and K4 advanced frame. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a microprocessor knee (L5848, L5845, L5828, L5856, L5850), VASS, shock reducing pylon, 
and K4 advanced frame.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more care and therapy. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services she needs including therapy 
services in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
femur fracture after a fall. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient 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 this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
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 this is medically necessary. The Plan denied your 
request. The Plan says care could be received 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. 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 medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an introduction of a needle and/or catheter (36903) provided 
on December 21, 2021. 
 
You asked the Plan to pay for an introduction of a needle and/or catheter. You say that the service at issue was 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the available records do not 
support the service billed. 
 
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 36903 is "Introduction of needle(s) and/or catheter(s), 
dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter 
placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery 
through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological 
supervision and interpretation and image documentation and report; with transcatheter placement of 
intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment." 
 
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 an introduction of a needle and/or catheter. Our reviewer 
says that the service at issue does not meet criteria for reimbursement. Our reviewer found that the procedure 
report does not include documentation of stent in peripheral dialysis segment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an introduction of a needle and/or catheter have not been met. Therefore, we 
decided that the Plan does not have to pay for an introduction of a needle and/or catheter (36903) provided on 
December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214, 99204) and a routine 
electrocardiogram (ECG) with at least 12 leads (93000) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and a routine electrocardiogram (ECG) with at least 12 leads. 
You say that you spoke with the Plan representative and all visits require authorization, and the authorization 
looks like it requires a primary care physician signature and a doctor signature. The Plan denied your request. 
The Plan says they approve out-of-state specialty services when the care is not available in your state, and 
cardiology services are available in your state. The Plan also says that prior authorization is required for non-
emergent medical services out of your state, and there was no information that the office visit to the provider 
was an emergency. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99214, 99204) and a routine electrocardiogram (ECG) with at least 12 leads (93000) to be 
provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of a breast localization device provided on 
September 29, 2021. 
 
You asked the Plan to pay for the breast localization device placement. You say that the information submitted 
regarding this code supports that payment should be made. The Plan denied your request. The Plan says this 
outpatient hospital claim cannot be paid without reporting the appropriate device code along with 19281. 
 The Plan must follow Medicare rules. Medicare rules say that the I/OCE applies to all outpatient hospital 
claims. The edits have various rationales and dispositions. 
 
In this case, code 19281 is a device-dependent code. This was denied due to OCE edit 92. According to the 
Integrated OCE (IOCE) CMS Specifications V22.2, this edit is triggered when a device-dependent code is 
reported without a device code. This results in the claim being returned to provider, i.e., denied. This denial is 
shown to be correct as the claim does not include a device code as required. Therefore, we decided that the 
Plan does not have to pay for the placement of a breast localization device provided on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
tried a course of conservative treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa. Our physician reviewer found 
that the enrollee has a history of bilateral knee pain. She had a cortisone injection of the right knee in July 
2021, with substantial lasting relief. She does not have radiographic evidence (x-ray or MRI) of osteophytes in 
the knee joint or sclerosis in bone adjacent to the knee. This class of viscosupplemental medication has not 
been found to be clinically effective or approved for use in the patellofemoral joint. The documentation does 
not support that the Euflexxa is medically reasonable or necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on October 7, 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 Barium Swallow Study to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a Barium Swallow Study. You say that you are the only company that 
provides mobile modified barium swallow study. The Plan denied your request. The Plan says there are no 
details as to why the member cannot go to an in-network facility to have this test performed. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a Barium Swallow Study to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve the Ondansetron. You say that you would like reconsideration because the 
Ondansetron is medically necessary. The Plan denied your request. The Plan says this drug is not covered 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for the Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network infectious disease referral. 
 
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 required medical care can be provided a network infectious disease consultant. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network infectious disease referral.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the over-the-counter COVID-19 home testing kits provided on January 
19, 2022. 
 
You asked the Plan to pay for the over-the-counter COVID-19 home testing kits. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are 
not covered. 
 
The Plan must follow Medicare rules. CMS says that Plans and insurers are required to cover at-home over-the-
counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the At-Home coronavirus tests have been met. Specifically, the At-Home coronavirus tests were 
purchased after the date of January 15, 2022. Therefore, we decided that the Plan has to pay for the over-the-
counter COVID-19 home testing kits provided on January 19, 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: 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 admission. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the medical necessity criteria were not met and the enrollee's 
needs could be met at a lower level of care. 
 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that the patient requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. There is no 
documentation that daily skilled services are required. The patient is walking household distances with 
a wheeled walker with stand-by to minimum assistance and is supervision/set-up for transfers. The provided 
records do not document a significant decline in the patients functional status to necessitate daily inpatient 
skilled therapy services. There is no documentation that the patient requires the services on an inpatient basis, 
only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care 
facility on a part time basis appear appropriate 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).