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

 
We decided that the Plan does not have to pay for the nerve conduction testing provided on September 29, 
2021. 
 
You asked the Plan to pay for the nerve conduction testing. You say that the services were medically necessary. 
The Plan denied your request. The Plan says there is no signed physician order for the services in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests not ordered by the physician who 
is treating the beneficiary are not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nerve conduction testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the nerve conduction testing provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2310, 
E2313, E2377) for the enrollee. 
 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 upper limb strength and function are therefore 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 additional accessories are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and 
puff, head array, etc.). The enrollee 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 enrollee's upper extremity strength and function support that the enrollee 
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 (E2310, E2313, E2377) 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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient was admitted for surgical management of an ankle fracture after a fall. 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. In conclusion, 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. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on September 30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan 
denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer 
says that the ambulance services are not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such 
as stretcher van, wheelchair van) were contraindicated for the enrollee on September 30, 2021. The reviewer 
found that the documentation does not support that the patient needed the expertise, services and lifesaving and 
life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The reviewer 
also found that the documentation does not support that the ambulance transport on the date of service in this 
case was medically reasonable and necessary for the 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and 
ground mileage (A0425) provided on September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion with a Minuteman device (22612). 
 
You asked the Plan to pre-approve spinal fusion with a Minuteman device. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 spinal fusion with a Minuteman device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Minuteman interspinous process device is experimental. More research 
is needed to show it is safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion with a Minuteman device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve spinal fusion with a Minuteman device (22612).
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 reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the patient is living in an assisted living facility and has a history of 
polyneuropathy, degenerative disc disease, and hypertension. He has weakness and episodes of falling. 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. In conclusion, 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehabilitation care to gain your strength 
back. You say that if you don't receive more therapy, you may not heal properly after having your surgery 
procedure. 
 The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of an 
IRF admission 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 you are medically stable do not need physical medicine and rehabilitation physician 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. There are no acute rehabilitation nursing needs identified or documented in the 
record. While you may benefit from physical therapy and occupational therapy you will not be able to tolerate 
and hence does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach to daily therapy in an IRF. You will not make significant functional 
recovery in an IRF in a predicted period of time as required by CMS guidelines. At the current medical 
stability, and low functional level, your rehabilitation can be safely provided at a lower intensity and alternate 
setting. An IRF admission is not medically necessary based on medical stability and lack of medical 
complexity and lack of acute rehabilitation nursing needs. Your rehabilitation needs can be met at a lower 
intensity setting. The documentation does not support the necessity for admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
4, 2021, to June 7, 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 DRG was updated in this case.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 597 (MALIGNANT BREAST DISORDERS 
WITH MCC). 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 services at issue in this case were not supported by the medical records. Our physician reviewer 
found the enrollee presented to the Emergency Department (ED) with shortness of breath and fatigue requiring 
blood transfusion and low dose oxygen (2L) due to 88% Sp02 and hemoglobin dropping to 8. No arterial blood 
gas was seen as having been performed to show low Pa02, nor was there evidence of requiring 5L/m or more of 
oxygen support or need of bilateral positive airway pressure (BiPAP) to qualify as having acute respiratory 
failure with hypoxia to justify DRG 597. The more appropriate DRG in this case would be 598 (MALIGNANT 
BREAST DISORDERS WITH CC) based on the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from June 4, 2021, to June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee on June 14, 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 provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the denied services are not supported in the medical records. They should not be reported 
separately in this case, as the enrollee was inpatient at this time. 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 hospital services provided to the enrollee on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99213) on November 5, 2021, with 
an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit. You say that the provider at issue has been your 
physician for several years. The Plan denied your request. The Plan says rules for payment for out-of-network 
care have not been met. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a physician office visit (99213) on November 5, 
2021, with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methocarbam tablet 500mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication is a benefit exclusion. 
 
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 Methocarbam tablet 500mg 
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has no contractual obligation to cover services that are not medically necessary, 
or that do not meet Medicare criteria for coverage. 
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found based on the medical 
records provided, there is no documentation that you have a personal mobility deficit that impairs participation 
in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary 
locations within the home. The records report that you are independent with walking, stairs, dressing, and 
shopping with no reported need for any assistive device. Your lower extremity power was reported as normal 
in January 2022. The device is reportedly being requested to go to the park, museum and for use for 
employment. There is no documentation that your mobility deficit cannot be helped by the use of a walker, 
cane, or manual wheelchair. There is no documentation that you could safely operate the scooter. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution 
injection. 
 
You asked the Plan to pre-approve percutaneous lysis of epidural adhesions using solution injection. You say 
that you have been receiving these injection services for 3 years and 3 months. You say that the injections help 
your back pain and help you get through the day. The Plan denied your request. The Plan says the office notes 
do not explain why the requested procedure was requested. 
 
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 percutaneous lysis of epidural 
adhesions using solution injection. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low 
back pain with radicular symptoms. The progress notes state had a lumbar discectomy, but the MRI does not 
address this past history. The enrollee takes Diclofenac, Tylenol, Gabapentin, Flexeril and Tizanidine. She has 
tried physical therapy. The enrollee has received lysis of epidural adhesions in the past. Our physician reviewer 
says that this is considered an experimental and investigational procedure.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous lysis of epidural adhesions using solution injection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions 
using solution injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotator cuff reconstruction (23420) and shoulder 
arthroscopy (29823) provided on August 9, 2021. 
 
You asked the Plan to pay for the rotator cuff reconstruction (23420) and shoulder arthroscopy (29823). The 
Plan denied your request. The Plan says procedure codes 23420 and 29823 are not supported by the medical 
records submitted. 
 
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 23420 is reconstruction of complete shoulder (rotator) 
cuff avulsion, chronic (includes acromioplasty). 
 
  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 rotator cuff reconstruction (23420) and shoulder 
arthroscopy (29823). Our reviewer says that the documentation submitted was reviewed and does not meet the 
criteria for coverage. Our reviewer found that the operative report does not include enough documentation to 
support a reconstruction has been performed and not a repair. The operative report also does not include 
debridement of 3 or more discrete structures where no other work was performed. Therefore, these procedures 
cannot be verified. 
 
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 rotator cuff reconstruction (23420) and shoulder arthroscopy (29823) have 
not been met. Therefore, we decided that the Plan does not have to pay for the rotator cuff reconstruction 
(23420) and shoulder arthroscopy (29823) provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99100) provided on June 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of B under the 
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into 
payment for other services.  
 No separate payment can be made for the anesthesia services. 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 the services (99100) provided on June 16, 2021.