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

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records show that you have a history of 
stroke with right-sided weakness and a left below-knee amputation with mobility impairments. The Plan denied 
the requested PWC due to a home entry/environment issue; however, the documentation shows you had repairs 
and a ramp entry was completed. You have documented functional impairments that meet the criteria for the 
Group 2 PWC. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the head 
(70544) and an MRA of the neck (70547). 
 
You asked the Plan to pre-approve MRA imaging services. You say that these imaging services are medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage of angiography of the head and 
neck are not met in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs 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 MRA imaging services. Our reviewer 
says that the requested imaging services are not medically necessary and reasonable in this case. Our physician 
reviewer found the provided records do not show that you had an existing stroke or signs or symptoms 
suggestive of such, intracranial bleeding, or any personal or family history of blood vessel abnormalities. There 
was no evidence from reported symptoms or physical findings suggesting aneurysm or other blood vessel 
abnormality, and documentation suggests occipital neuralgia and muscle tension which would not warrant 
MRA. Therefore, this request for MRA will be considered 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 MRA imaging services have not been met.  Therefore, we decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of 
the head (70544) and an MRA of the neck (70547).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 16, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for practitioner services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and authorization was not obtained. 
 
 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 practitioner services provided on November 16, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on January 
13, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a Professional 
Component (PC)/Technical Component (TC) Indicator of 8. This indicator identifies the professional 
component of clinical laboratory codes for which separate payment may be made only if the physician 
interprets an abnormal smear for hospital inpatient. This code was billed with a place of service of 22 
(outpatient hospital) which is not considered an appropriate place of service for this code. Based on this 
information, we decided that Medicare rules for coverage of the blood smear services have not been met. 
Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
January 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on October 18, 2021. 
 
You asked the Plan to pay for occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
  The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fiber gelling wound dressing (A6197) provided on 
November 1, 2021. 
 
You asked the Plan to pay for fiber gelling wound dressing. You say that you have provided records to support 
the services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code A6197 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A6197 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of fiber gelling wound dressing have not been met. Therefore, we decided that the Plan does not have to pay for 
fiber gelling wound dressing (A6197) provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on February 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70450) provided on February 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 14, 2021, 
to December 23, 2021. 
 
You asked the Plan to pay for the home health care. You say that you were advised this was not a rule for the 
enrollee's plan. You say that the claim should be reprocessed accordingly. The Plan denied your request. The 
Plan says the RAP claim was not submitted until January 28, 2022, more than 5 days after the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, December 14, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from December 14, 2021, to December 23, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
20, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation for a benign thyroid nodule 
(CPT code 60699). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of radiofrequency ablation for a benign 
thyroid nodule has not been demonstrated in the peer-reviewed medical literature. The Plan states it has not 
been firmly established that radiofrequency ablation is a valid alternative to conventional treatments for 
nontoxic thyroid nodules. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation and the medical literature do not support that radiofrequency 
ablation of a benign thyroid nodule is medically reasonable and necessary for the enrollee in this case. It has 
not been shown that radiofrequency ablation is at least as beneficial as an existing and available medically 
appropriate alternative. 
  
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation for a benign thyroid nodule (CPT code 60699).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with hypoxic respiratory failure due to aspiration pneumonia. The record indicate that the 
enrollee is improving but still requires acute care services before transitioning to a lower level of care. The 
enrollee continues to receive acute care services, and these have not been denied. The medical record does not 
indicate that the enrollee requires services that he is not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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. 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. The Plan denied your request. The Plan says 
an epidural steroid injection does not meet the Medicare coverage criteria 
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found in this 
case, there is no radiologic documentation of canal impingement by degenerative disc disease, central canal 
stenosis or osteophytes. The review has determined that it is not medically necessary or reasonable for this 
enrollee to have the caudal ESI as requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vivistim Paired Vagus Nerve Stimulation (CPT 
code 64568). 
 
You asked the Plan to pre-approve the services. You say that this procedure is very likely to significantly 
improve the enrollee's upper limb function and abilities in many areas of the enrollee's life. The Plan denied 
your request. The Plan says the requested procedure is considered experimental and unproven. The Plan states 
there is not enough medical proof that shows the safety and/or success of implantable vagus nerve stimulators 
when used for this reason. 
 
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 currently available evidence is limited and not high quality to sufficiently show that this device 
provides lasting improvement in overall function and spasticity to justify this request at this time. Therefore, 
this request for vagus nerve stimulator will be considered 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vivistim Paired Vagus Nerve Stimulation (CPT code 64568).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide hours (21 hours per week). 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says the reduction in services to 6.5 hours/week is appropriate. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional hours. Our reviewer says 
that the requested additional aide hours are not medically reasonable or necessary. Our physician reviewer 
found you are medically stable without any recent hospitalizations or medical complications. The approved 
weekly hours allow for appropriate support and care. The documentation does not support that the additional 
hours are needed to provide adequate support. 
 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 additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health aide hours (21 hours per week).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for lower intestinal endoscopic procedures, 
endoscope introduced distal to duodenum (00813) provided October 6, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that please reprocess the claim for payment 
based on the extensions in place for COVID-19. The Plan denied your request. The Plan says the claim was 
submitted past the timely filing limitation and does not meet the exception criteria guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia services was not filed until 02/11/2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the anesthesia for lower intestinal endoscopic procedures, endoscope 
introduced distal to duodenum (00813) provided October 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested visits are medically necessary. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits are not medically reasonable or necessary. Our physician reviewer found the documentation 
doesnt support that the enrollee requires additional skilled rehab services to provide treatment that is medically 
necessary. The enrollee does not require additional skilled rehab services to effectively provide treatment, care, 
and/or services in order to improve the enrollees condition, perform a maintenance program to maintain the 
enrollees condition and/or prevent deterioration. The enrollee has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health occupational therapy for the enrollee.