Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot with ankle 
feature (L5968, L5981). 
 
You asked the Plan to pre-approve a prosthetic leg with an advanced foot with ankle feature. 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 microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 prosthetic leg with an advanced foot 
with ankle feature. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found criteria have not been met for the prosthetic leg with advanced foot with ankle feature. The 
documentation does not support that the patient is a K3 ambulator as he was recently approved a power 
mobility device to assist with activities of daily living (ADLs). 
 
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 prosthetic leg with an advanced foot with ankle feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot with 
ankle feature (L5968, L5981).
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 acute inpatient rehab admission due to 
decreased in functional ability. The Plan denied your request. The Plan says the records do not reflect that you 
have the need for medical monitoring by a rehabilitation physician, medically necessary care may be provided 
safely in a different level of care. 
 
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 do not require the intensity of services provided at 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 procedure code A0382-RH billed for date of service August 
7, 2022. 
 
You asked the Plan to pay for procedure code A0382-RH. You say that this claim was denied as a duplicate in 
error. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A0382-RH has a Status Indicator of I on the Physician Fee Schedule. This means 
that procedure code A0382-RH is not valid for Medicare purposes. Based on this information, we decided that 
Medicare rules for coverage of procedure code A0382-RH have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A0382-RH billed for date of service August 7, 2022.
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 are a high fall risk and are worried about getting 
an infection if you don't receive the proper care. The Plan denied your request. The Plan says you do not meet 
the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for surgical repair of a hip after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical records support 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 you 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 1, 2022.
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 the enrollee has multiple medical issues that need 
ongoing and frequent medical monitoring. You say the enrollee continues to benefit from and need ongoing 
skilled rehab and nursing services. The Plan denied your request. The Plan says criteria for admission to a SNF 
has not been met. 
 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 the enrollee does have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Clinical 
documentation shows that the enrollee has not had acute functional or clinical status change in the current level 
of care. The enrollee continues to require close medical monitoring, skilled nursing and skilled therapy, thus 
transitioning the enrollee to a level of care with only skilled nursing and therapy (SNF) is not medically 
appropriate. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision excessive skin and subsequent tissue, 
abdomen, and excision skin, abdomen, infraumbilical panniculectomy. 
 
You asked the Plan to pre-approve excision excessive skin and subsequent tissue, abdomen, and excision skin, 
abdomen, infraumbilical panniculectomy. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 excision excessive skin and subsequent 
tissue, abdomen, and excision skin, abdomen, infraumbilical panniculectomy. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
reviewer found you had weight loss after bariatric surgery and have a pannus. The record provided is 
insufficient to document that there are complicating factors as inability to walk normally, chronic pain, 
ulceration created by the abdominal skin fold, or intertrigo dermatitis which would result in the requested 
procedure being reconstructive in nature. The provided records are insufficient to establish that the coverage 
criteria are satisfied. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excision excessive skin and subsequent tissue, abdomen, and excision skin, 
abdomen, infraumbilical panniculectomy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve excision excessive skin and subsequent tissue, abdomen, and excision skin, abdomen, 
infraumbilical panniculectomy.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that this treatment was approved by the enrollee's previous 
plan. You say that the enrollee switched plans as of the new year. You also say that it is imperative these 
surrounding structures be spared as much as possible while providing adequate radiation to the tumor area. The 
Plan denied your request. The Plan says that the requested treatment is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IMRT. Our reviewer says that the 
requested IMRT is considered medically reasonable and necessary in this case. Our physician reviewer found 
the requested IMRT is considered a useful tool to reduce toxicity and improve the lung, heart and skin dose 
distributions. The reviewer found that the requested treatment is safe and effective. Therefore, the reviewer 
found that the IMRT is medically reasonable and necessary 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 IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity modulated radiation therapy (IMRT).  
 
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 physician services (97140, 99202, G0283) provided by a 
chiropractic provider on July 15, 2022. 
 
You asked the Plan to pay for physician services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the services at issue are not a covered benefit 
when provided by a chiropractic provider. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for physician services (97140, 99202, G0283) provided by a chiropractic 
provider on July 15, 2022.
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 the SNF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for coverage for admission to a SNF. 
 
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 or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) provided on September 6, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, this service is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup (D2950) 
provided on September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four additional units of code 87481. 
 
You asked the Plan to pay for 4 more units of 87481. You say that you have provided records to support the 
coding and medical necessity of these services. The Plan denied your request. The Plan says the records only 
support one unit of this code. 
 
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 87481 is infectious agent detection by nucleic acid (DNA 
OR RNA); candida species, amplified probe technique.  

We find that four additional units of CPT code 87481 are not supported in the medical record. Specifically , 
you billed a total of 5 units of code 87841.  However, your medical records only list one candida species 
(candida albicans) being tested. That is why only 1 unit of this code (which has already been paid), is supported 
in the medical records. Based on this information, we decided that Medicare rules for coverage of 4 units of 
87481 have not been met. Therefore, we decided that the Plan does not have to pay for four additional units of 
code 87481.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 95938 and 95939 provided on June 27, 2022. 
 
You asked the Plan to pay for procedure codes 95938 and 95939. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make 
a determination within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for these services based on Medicare criteria. Therefore, we decided that the Plan has to pay for 
procedure codes 95938 and 95939 provided on June 27, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee was on Fosamax for five year.s You also 
say that the enrollee is requesting to start on Prolia instead. The Plan denied your request. The Plan says the 
enrollee has not tried and failed the preferred drugs, an n oral bisphosphonate drug and zoledronic acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed any of the Plan's preferred drugs. The reviewer found that there is no 
indication that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
drugs. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is not an ideal candidate for traditional 
chemotherapy or surgical intervention. You also say that immunotherapy is the safest option for the enrollee. 
The Plan denied your request. The Plan says the requested treatment is not recommended by the Food and Drug 
Administration for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
requested use of Keytruda is not medically necessary. Our physician reviewer found the record indicates that 
the requested drug is being used as first-line therapy and if unsuccessful, chemotherapy would be prescribed. 
The reviewer found that the Food and Drug Administration has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested drug 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that this device is medically 
necessary for the enrollee. The Plan denied your request. The Plan says experimental and investigational 
procedures are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided and the Medicare-approved major 
drug compendia, there is no documentation that the MyoPro powered arm brace (L8702) at issue in this case 
meets all Medicare criteria for 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 a MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace (L8702).