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

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service March 26, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service March 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00170) provided on October 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that the anesthesia services were medically 
necessary. The Plan denied your request. The Plan says the anesthesia services are not covered when provided 
out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the anesthesia services (00170) provided on October 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular repair of infrarenal aorta and/or iliac 
artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, 
all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft 
extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all 
angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture 
(eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) (34703) and inpatient hospital care. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show a growth of the enrollee's aneurysm of 
more than 1 cm in a year or 0.5 cm in 6 months. The Plan states the enrollee's aneurysm is 3.6 cm and the 
enrollee's records do not describe any of the complications or issues in the Plan's criteria. 
 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that there is no documentation of growth of the aneurysm of more than 1 
cm in a year or 0.5 cm in 6 months. The abdominal aneurysm is 3.6 cm and records do not describe any of the 
complications. The review has determined that endovascular repair of infrarenal aorta and/or iliac artery(ies) by 
deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection (34703) in this 
case 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-
uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all 
associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the 
level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the 
renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, 
penetrating ulcer) (34703) and inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and accessories. You say that this is 
necessary. The Plan denied your request. The Plan says your current wheelchair is functioning, does not need 
replacement and is not beyond repair. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchairs may be replaced in cases of loss or 
irreparable damage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 standard power wheelchair and accessories have not been met. Specifically, the record 
does not show the wheelchair sustained loss or irreparable damage, and because the wheelchair is less than 5 
years old it is still within its reasonable useful lifetime so replacement due to wear is not covered. Therefore, 
we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pancreas transplantation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that pancreas transplants 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 services. Our physician 
reviewer found that the enrollee has a diagnosis of type 1 diabetes mellitus with hypoglycemia with coma. It is 
documented that the enrollee has some lows following peak blood glucose levels. The documentation notes that 
the enrollee has not been bolusing before meals, mostly right after. It is documented that the enrollee has had 
good glycemic control over the years and had no complication from his diabetes. It is noted that the last A1c 
was stable compared to previous. The documentation in the case file does not support that the enrollee is beta 
cell autoantibody positive, or demonstrates insulinopenia, defined as a fasting C-peptide level that is less than 
or equal to 110% of the lower limit of normal of the laboratory's measurement method. There is insufficient 
documentation of recurrent, severe, acutely life-threatening metabolic complications that require 
hospitalization. Therefore, the request 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve pancreas transplantation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you do not meet all of the requirements. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical 
history of congestive heart failure, arthritis, and obesity and is living at home with weakness. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. 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 inpatient rehabilitation facility (IRF) admission and services.
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 due to mitigating factors such as tissue mobility, tumor 
size, location of the lesion, and enrollee's preference it was determined that IG-SRT is medically necessary. 
You also say that the enrollee does not wish to pursue surgical option. The Plan denied your request. The Plan 
says the provided documentation does not support that the enrollee has a condition that is known to respond 
well to radiation therapy. 
 
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 IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested treatment is not the community standard of care. Therefore, the reviewer found that the requested treatment is not medically 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation therapy (IGRT).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for therapy services (97166) provided on March 13, 2020. 
 
You asked the Plan to pay for therapy services. You say that these services should be paid and were reported 
correctly. The Plan denied your request. The Plan says that this claim is denied. 
 
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 not provided a clear reason for denial in this case, nor 
has the Plan supported a denial reason with evidence and a relevant citation. Therefore, we decided that the 
Plan has to pay for therapy services (97166) provided on March 13, 2020.  
 
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: Favorable

 
We decided that the Plan has to pre-approve the endovenous ablation therapy (36475). 
 
You asked the Plan to pre-approve the endovenous ablation therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the service is covered when criteria listed in the 
Medicare Rules section 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 the endovenous ablation therapy. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the documentation meets 
coverage criteria and supports the medical necessity of the treatments in question. There is satisfactory 
documentation of symptom severity including significant symptoms attributable to the varicose veins with 
documentation of satisfactory arterial perfusion.  There is documentation of severe reflux in the veins to be 
treated in the absence of deep vein thrombosis (DVT). There is satisfactory documentation of long-term efforts 
to treat conservatively. Anatomic considerations for endovenous ablation are also 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 the endovenous ablation therapy have been met. Therefore, we decided that the 
Plan has to pre-approve the endovenous ablation therapy (36475).  
 
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 pay for procedure code J3490 billed for date of service December 
27, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says the service 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 CPT code. 
 In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. We find that CPT code J3490 
was billed to identify a Bupivacaine injection, which is a local anesthesia and therefore not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for date of 
service December 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex device placement surgery. 
 
You asked the Plan to pre-approve a vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a vertiflex device placement surgery. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vertiflex device placement surgery.
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 live alone and cared for yourself before this stay, 
and now you are not able to even get up the ramp to enter your home. The Plan denied your request. The Plan 
says your records do not show that your rehabilitation needs are complex, and you do not need an intensive 
team for your care, services needed can be provided safely in other settings, a skilled nursing facility, home 
with home health services or home with outpatient therapy. 
 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are needing continuation of rehabilitation 
immediately because you broke your hip. The Plan denied your request. The Plan says your records do not 
show you are able to take part in 3 hours of therapy a day at least 5 days a week or 15 hours per week, services 
needed can be provided safely in other settings, a skilled nursing facility, home with home health services or 
home with outpatient therapy. 
 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq (J8499). 
 
You asked the Plan to pre-approve Myrbetriq. You say that failure to approve this medication could lead to 
increase in cognitive issues and a decrease in effectiveness of Parkinson's medications. The Plan denied your 
request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq (J8499).  
 
Benefits for Myrbetriq may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve lung transplantation. 
 
You asked the Plan to pre-approve lung transplantation. You say that it is imperative that you have clearance to 
move forward in the listing for lung transplantation. The Plan denied your request. The Plan says that the 
enrollee does not meet criteria. 
 
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 lung transplantation. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you have been treated with chronic immunosuppressives and has exhausted all reasonable 
treatment except for lung transplantation. Recent notes describe that the enrollee is medically cleared for 
transplantation without evidence of cancer. Therefore, a request for being on the transplant list is reasonable 
and medically 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 lung transplantation have been met. Therefore, we decided that the Plan has to 
pre-approve lung transplantation.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on May 26, 2021. 
 
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 services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that, on Medicare claims, these HHRGs are represented as 
Health Insurance Prospective Payment System (HIPPS) codes. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct HIPPS 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered on May 
26, 2021.