Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on July 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.   
In this case, the start of care date is July 7, 2022. The NOA was not received by the Plan until August 21, 2015. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found certainly using ultrasound on a daily basis is not unreasonable to offer but not necessary. The 
device itself is FDA approved for use with ultrasound though that in and of itself does not mean that daily 
imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill 
for daily simple simulations and/or IGRT for a technology for which need has not been established by 
published data or supported by consensus guidelines is not necessary. Billing for daily IGRT which would not 
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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74221 and 74248 billed for date of service 
July 1, 2022. 
 
You asked the Plan to pay for procedure codes 74221 and 74248. The Plan denied your request. The Plan says 
payment for codes 74221 and 74248 is bundled. 
 
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 74221 
is a column II code to column I code 74246 with a modifier indicator of 0. We have also confirmed that code 
74248 is a column II code to column I code 74221 with a modifier indicator of 0. The column II codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 74221 and 74248 billed for date of service July 
1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable underpads (A4554). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need the incontinence supplies due 
to having a chronic cough. You have accidents and you need the liner and pads. The Plan denied your request. 
The Plan says the requested item is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve disposable underpads (A4554).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat echocardiography, transthoracic (TTE) (93306). 
 
You asked the Plan to pre-approve a repeat TTE. You say that the enrollee had a repeat echocardiogram in 
September 2021. You say that diastolic analysis was not completed. You say that with a sudden onset of 
swelling, a repeat echocardiogram is necessary to ensure no change in cardiovascular function. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that without clinically documented, discrete (abrupt 
change in signs and symptoms) episodes of deterioration, it is not generally medically necessary to repeat TTE 
assessments more frequently than annually, unless done to evaluate the response to therapeutic intervention. 
 
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 TTE. Our reviewer says that 
the requested TTE is not medically necessary. Our physician reviewer found the provided documentation does 
not indicate a change in cardiac status that would support the medical necessity of a repeat TTE. Therefore, the 
reviewer found a repeat TTE IS not medically reasonable or necessary at this time. 
 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 TTE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat echocardiography, transthoracic (TTE) (93306).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the chest. 
 
You asked the Plan to pre-approve a CT of the chest. 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 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 CT of the chest. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the record indicates 
that the enrollee has had a cough for three months. The record indicates the enrollee has gained weight, has an 
elevated brain natriuretic peptide, and reduced ejection fraction. The provided records do not indicate the 
medical necessity or reasonableness, as defined by Medicare rules, of the requested service at this time. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 CT of the chest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wipes. 
 
You asked the Plan to pre-approve the wipes. You say that the wipes are medically necessary. The Plan denied 
your request. The Plan says the wipes (also called as personal wipes, disposable wipes or cleansing wipes) are 
not covered because they are not medical in nature and are regularly and primarily used by persons who do not 
have a specific medical need for them. 
 
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 the wipes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertical shock reducing pylon feature (L5988), 
Supracondylar Suspension System (L5670), and protective covering (L5962). 
 You asked the Plan to pre-approve a vertical shock reducing pylon feature, Supracondylar Suspension System, 
and protective covering. You say that these items are medically necessary. The Plan denied your request. The 
Plan says these items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 vertical shock reducing pylon feature, 
Supracondylar Suspension System, and protective covering. Our reviewer says that these items are not 
medically necessary. Our physician reviewer found detailed documentation is not evident regarding the need 
for more than one knee suspension for one prosthesis. Additionally, the already approved prosthesis included 
gel liners that have extra padding at the end. The rationale is not evident that an additional special cushion is 
needed. Moreover, additional features/components are not indicated outside of a medical need. This is not 
demonstrated in the documentation provided for review. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 vertical shock reducing pylon feature, Supracondylar Suspension System, and 
protective covering have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
vertical shock reducing pylon feature (L5988), Supracondylar Suspension System (L5670), and protective 
covering (L5962).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are worried you will not heal properly if you are 
discharged too early. The Plan denied your request. The Plan says the medical necessity criteria are not met for 
the continued SNF stay. 
 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You 
do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services (72148) provided on June 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the MUE value 
has been exceeded. 
 
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 Plan argues that one unit of code 72148 was billed for the date of service in 
question on two separate claims, exceeding the MUE value of 1. However, the Plan has not submitted 
documentation showing that this code was billed twice. The records only show one unit of code 72148 billed 
for the date of service in question. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the services (72148) provided on June 8, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for admission 
to the LTACH which would give them every opportunity to improve and return to their prior level of function. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for an LTACH admission. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The record indicates that the enrollee is improving but 
still requires acute care services before transitioning to a lower level of care. The Plan has approved ongoing 
care in the current acute care setting.  
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and follow-up visits with an out-of-
network (OON) oncologist and dermatologist. 
 You asked the Plan to pre-approve a consultation and follow-up visits with OON providers. You say that the 
enrollee has two types of T-Lymphoma and the Plan's in-network providers are not qualified to treat the 
enrollee's condition. The Plan denied your request. The Plan says the requested provider is out-of-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 consultation and follow-up visits with 
OON providers. Our reviewer says that a consultation and follow-up visits with the requested OON providers 
are not medically necessary. Our physician reviewer found the record indicates that the enrollee has T-cell 
lymphoma and mycosis fungoides. The plan has indicated that in-network providers are available or adequate 
to meet the enrollee's medical needs. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not recommended. 
 
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 consultation and follow-up visits with OON providers have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a consultation and follow-up visits with an 
out-of-network (OON) oncologist and dermatologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the service was authorized. The Plan denied your 
request. The Plan says the requested ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief for three months. 
 
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 ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee had at least 50% pain relief for 3 months. Therefore, the reviewer found that a repeat 
ESI 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says this request is considered investigational and therefore 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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (64628 and 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you prefer to be admitted to acute rehab because you 
were independent and active before coming to the hospital and want to return to being independent. The Plan 
denied your request. The Plan says the IRF services you requested do 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is expected to make measurable 
functional gains as well as improve their medical status within a reasonable period of time sufficient for a safe 
discharge to the community. The Plan denied your request. The Plan says the IRF services requested do 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee 
does require physical therapy and occupational therapy services, but the medical records provided do not 
clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. The enrollee is 
tolerating and benefiting from treatment in the skilled nursing facility. 
 
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 IRF admission and services.