Persius/hicric huggingface dataset:
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 enrollee needs this service. The Plan denied 
your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least 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 indicates that 
the enrollee's last ESI was performed on October 11, 2022, less than 3 months ago. Therefore, the reviewer 
found that a repeat ESI 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 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 15, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the services are not 
covered by Medicare when done by this type of doctor. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) and a 
Licensed Professional Counselor are not eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT) and a Licensed Professional Counselor. Medicare says that a Marriage Family Therapist (MFT) and a 
Licensed Professional Counselor are not eligible to participate in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for psychotherapy provided on July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee does not satisfy the criteria for 
coverage for the ILR. 
 
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 placement of an ILR. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is whether the requested authorization for placement of an ILR is medically 
appropriate and necessary. There is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an ILR in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
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 would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting 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 enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).

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 LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's return to acute care admission post discharge, the enrollee has a need for increased monitoring, and the need of daily physician involvement. The Plan denied your request. The Plan says a LTACH admission is not medically necessary, and the enrollee can safely receive care in a hospital setting.

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 that there is no evidence that the enrollee requires services that are not currently available. The enrollee can remain at the current acute care hospital then can be transferred or discharged to a lower level of care for any ongoing long term care needs.

 

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchoscopy with balloon occlusion. 
 
You asked the Plan to pre-approve bronchoscopy with balloon occlusion. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested 
bronchoscopy with balloon occlusion services are not medically reasonable and 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 bronchoscopy with balloon occlusion. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee is a 68-year-old man with severe chronic obstructive 
pulmonary disease. On September 15, 2022, it is documented that the enrollee's dyspnea has improved with 
exercise. "He is able to take a shower and walk longer distance without being short of breath. If he is doing 
more manual labor or bending down, he still experiences some dyspnea." The enrollee's oxygen saturation was 
documented to be 93% on room air. A computed tomography (CT) scan on May 20, 2022, demonstrated 
centrilobular emphysematous changes. The documentation does not include blood gas testing, a high-resolution 
CT scan, a 6-minute walk test, or documentation of significant symptoms despite a supervised pulmonary rehabilitation program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchoscopy with balloon occlusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bronchoscopy with balloon occlusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 99417. You say that the code is valid. 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 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 99417 billed for date of service March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for COVID Test on May 15, 2022. 
 
You asked the Plan to waive the copayment for COVID Test. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each visit to a participating walk-in convenience are clinic. Covered services include walk-in 
convenience care clinics. Provider billed in the amount of $18.91. This is less than the copayment amount. 
Therefore, results in the total cost sharing amount of $18.91.  
 
You have been asked to pay a $18.91 copayment, which is less than the copayment for COVID Test. This 
item/service falls within the Physician/practitioner services, including doctor's office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for COVID Test on May 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and crown (D2740, D0220) provided on 
July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 7th, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray and crown (D2740, D0220) 
provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular stents. 
 
You asked the Plan to pre-approve vascular stents. You say that the records provided support that the requested 
service is medically necessary. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary for the enrollee's condition. 
 
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 vascular stents. Our reviewer says that 
vascular stents are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is duplex evidence of isolated left popliteal artery stenosis that was not described as high-grade.  
There is absence of an ankle-brachial index (ABI) result.  The isolated popliteal artery stenosis would not 
explain bilateral leg pain and swelling.  The history does not adequately suggest that the enrollee is having 
lifestyle limiting claudication or limb threat, and it is not clear if the enrollees history of lumbar spine issues 
with radiculopathy was considered. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular stents have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vascular stents.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0748). 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that this device is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that bone growth stimulators are covered as an adjunct to 
spinal fusion surgery for patients at high risk of pseudarthrosis due to previously failed spinal fusion at the 
same site or for those undergoing multiple level fusion. A multiple level fusion involves 3 or more vertebrae 
(e.g., L3-L5, L4-S1, etc). 
 
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 bone growth stimulator. Our 
reviewer says that the requested bone growth stimulator is not medically necessary. Our physician reviewer 
found records do not show that the spinal bones have failed to heal after nine months. The records do not show 
he has failed a previous spinal fusion at the same site of L3-4 or that the current surgery involved 3 or more 
vertebrae. 
 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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator (E0748).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires hospital level care for 
rehabilitation with close medical management. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the home ventilator is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and was 
recently hospitalized with an exacerbation. There is a diagnosis of opiate use disorder. VBG was consistent 
with CO2 retention, but there is no confirmation of chronic CO2 retention with ABG done while stable. If the 
enrollee does have chronic CO2 retention, he may benefit from BiPAP with AVAPS. But Medicare does not 
cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for blood bank physician services (86077) provided on May 23, 2022. 
 
You asked the Plan to pay for blood bank physician services. You say that this service was medically necessary 
and is supported in the medical record. The Plan denied your request. The Plan says that this claim was 
submitted with a secondary/manifestation diagnosis code as the primary diagnosis, and therefore was not 
submitted in accordance with Medicare guidelines. 
 
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. Specifically, the Plan has provided incomplete claim information for these 
services. This incomplete information includes only information about the rendering/billing provider. It does 
not include information for the service billed, the diagnosis code(s) reported, or any information on the 
beneficiary to verify that this is the correct claim. Without this information, we cannot confirm that this claim 
was submitted with incorrect information as stated by the Plan, and therefore, the Plan's denial is not 
substantiated in this case. Therefore, we decided that the Plan has to pay for blood bank physician services 
(86077) provided on May 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller and its related accessories. 
 You asked the Plan to pre-approve the expandable controller and its related accessories. You say that this 
equipment is medically necessary. The Plan denied your request. The Plan says the criteria for coverage of the 
expandable controller have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed 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 the expandable controller and its related 
accessories. Our reviewer says that the requested equipment is not medically reasonable and necessary. Our 
physician reviewer found based on the medical records provided there is no documentation that requested 
expandable controller and related hardware (E2313, E2377, E2311) meet Medicare criteria for medically 
necessary. Provided records document that you have 3/5 left upper extremity strength and are able to feed 
yourself thus indicating that you have adequate upper extremity strength and function to operate the 
wheelchair's power options with your 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 expandable controller and its related accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the expandable controller and its related 
accessories.
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 May 3, 2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99053 billed for date of service May 3, 2022.