Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the Psychotherapy services (90834) provided on July 8, 2021. 
 
You asked the Plan to pay for the Psychotherapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they require the taxonomy code on 
the claim form for payment consideration. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the Plan contract, and Medicare rules. We find that the Plan's denial reason is not 
supported based on Medicare guidelines. The provider's taxonomy number is included in the National Provider 
Identifier (NPI) which is listed on the claim form. Based on this information, we decided that Medicare rules 
for coverage of the Psychotherapy services have been met. Therefore, we decided that the Plan has to pay for 
the Psychotherapy services (90834) provided on July 8, 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 pay for acupuncture treatment provided from October 4, 2021, 
through October 21, 2021. 
 
You asked the Plan to pay for acupuncture treatment. You say that you called for benefits before seeking 
treatment and you also indicated that you had a variety of medical issues, including pulled hamstring, back pain 
and hips. The Plan denied your request. The Plan says since the diagnosis codes associated with the billing did 
not indicate the beneficiary has chronic low back pain, and the medical records do not support chronic low 
back pain, the claims were denied. The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. The file shows that the medical records do not support chronic low 
back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have 
not been met. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided 
from October 4, 2021, through October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds (12013) provided on 
September 26, 2021. 
  You asked the Plan to pay for the simple repair of superficial wounds (12013). You say that the codes are 
appropriately identified as separate procedures based on CPT guidelines and coding advice. You say that you 
disagree with the determination and the claim should be processed for payment. The Plan denied your request. 
The Plan says an appropriate modifier was not billed with this code edit. 
 
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, we have confirmed that code 12013 
is a column II code to column I code 21310. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the simple repair of superficial wounds (12013) provided on 
September 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional home health physical therapy (PT) 
visits (G0151). 
 
You asked the Plan to pre-approve additional home health PT visits. You say that the requested additional 
home health PT visits are medically necessary. The Plan denied your request. The Plan says the requested 
additional home health PT visits do not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional home health PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the documentation does not support that the 
additional unique skills of a professional therapist are required to safely and effectively provide treatment, that 
the services can be safely and effectively performed only by a therapist, or for physical therapy and 
occupational therapy, by or under the supervision of a therapist. The requested services are not part of a 
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to 
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. The enrollee has been instructed on safety measures, an emergency plan, and fall 
precautions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve six (6) additional home health physical therapy (PT) visits (G0151).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is not safe to go home and care for 
herself without additional therapy services. The Plan denied your request. The Plan says services can safely be 
received in 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 
the enrollee does not qualify for SNF coverage. Our physician reviewer found that the enrollee does not have 
documented skilled nursing needs or skilled therapy needs. The enrollees care needs can be provided at a 
lower level of 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (Q5105, J0606, J2501, & 90999) provided April 1, 
2021 to April 3, 2021. 
 
You asked the Plan to pay for the injections. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the claim was not billed with a required modifier. 
 
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 CPT codes Q5105, J0606, J2501, & 90999 are not supported in the medical record. Specifically, 
erythropoiesis stimulating agents (ESA) must be billed with a route of administration modifier (JA, JB or JE).  
 
 
 Based on this information, we decided that Medicare rules for coverage of the injections have not been met. 
Therefore, we decided that the Plan does not have to pay for injections (Q5105, J0606, J2501, & 90999) 
provided April 1, 2021 to April 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power scooter described by code K0806. 
 
You asked the Plan to pre-approve a Group 2 power scooter. You say that the documentation clearly shows that 
the enrollee requires the use of the scooter both in and outside the home. The Plan denied your request. The 
Plan says this cannot be covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 power scooters are denied as not 
medically reasonable and necessary as they have features not needed for use inside the home.  
 
Although this type of scooter may be appropriate, it is not covered by Medicare or the Plan. Therefore, we 
decided that the Plan does not have to pre-approve a Group 2 power scooter described by code K0806.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the items are necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Cancer Panel billed with CPT codes 
81163, 81435, 81437, 81218, 81236, 81307, 81317, 81351, 81404, 81405, 81406 and 81407 and provided on 
August 3, 2021. 
 
You asked the Plan to pay for the Comprehensive Cancer Panel. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this testing was not billed 
correctly. 
 
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 Comprehensive Cancer Panel. Our 
reviewer says that the documentation does not include peer-reviewed full manuscript evidence supporting this 
combination panel of multiple biomarkers, particularly regarding its composite validity/utility. Our physician 
reviewer found the documentation does not show that the results of the test will directly impact the treatment 
being delivered to the beneficiary. 
 
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 Comprehensive Cancer Panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the Comprehensive Cancer Panel billed with CPT codes 81163, 81435, 
81437, 81218, 81236, 81307, 81317, 81351, 81404, 81405, 81406 and 81407 and provided on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Depend adult diapers. 
 
You asked the Plan to pre-approve Depend adult diapers. You say that the items are necessary. The Plan denied 
your request. The Plan says the requested items are a convenience item and not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve Depend adult diapers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase  participation in 
bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G Orthotic device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. You asked the Plan to pre-approve the requested service. You say that you want to keep your pain down. The 
Plan denied your request. The Plan says you did not experience at least 50% improvement of pain for three 
months. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical 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 the requested service. Our physician 
reviewer found that you have chronic back pain. Your magnetic resonance imaging (MRI) shows disc 
degeneration at 2 levels. You had a caudal epidural steroid injection on September 7, 2021, but there is no 
documentation of the degree and duration of pain relief achieved. The request is to repeat the epidural. The lack 
of documentation of the degree and duration of pain relief achieved from the epidural precludes another one.  
At this point, the request is deemed 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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says the service is not considered medically necessary. 
 
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. The file shows that the injection is being requested for greater 
trochanteric pain. There is insufficient high-quality evidence to justify the use of PRP for the treatment of any 
condition except for within the confines of a well-designed clinical trial.  
 
Based on this information, we decided that Medicare rules for coverage of the requested services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve platelet rich plasma injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) colonography. 
 
You asked the Plan to pre-approve the requested testing. You say that the enrollee is unable to do a 
conventional colonoscopy. The Plan denied your request. The Plan says the standard of care is a colonoscopy. 
 
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 the requested testing. Our physician 
reviewer found that the enrollee has been diagnosed with hematochezia and melena. The standard of care is a 
colonoscopy. A virtual colonoscopy is only indicated in those whom a diagnostic or surveillance instrument 
colonoscopy of the entire colon is incomplete due to an inability to fully pass the colonoscope proximally, and 
a repeat attempt is not indicated; or in those with a valid contraindication to the safe performance of an 
instrument colonoscopy. Therefore, the requested CT scan is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) colonography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz knee injections. 
 
You asked the Plan to pre-approve Supartz knee injections. 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 viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when specific criteria are met. 
 
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 Supartz knee injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is insufficient 
documentation concerning the right knee being chronic for more than 3 months and there is record of a trial of 
intra-articular steroids. Therefore, the request is deemed not medically reasonable at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz knee injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Supartz knee injections.
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 does not meet 
criteria. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy 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.