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

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed more than 6 
months of conservative approaches. The Plan denied your request. The Plan says research has not found the 
procedure helpful 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 the requested services. Our physician 
reviewer found that interspinous process distraction devices remain experimental in spine surgery. More 
research is needed to show its safety and efficacy. Therefore, the requested services are 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 an interspinous stabilization device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has a complex medial 
meniscal tear. The Plan denied your request. The Plan says there is not an overgrowth of bones or narrowing of 
joint space. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for chondrocalcinosis of the left knee. The exam of the left 
knee reveals minimal effusion. The range of motion is 125/130. Tenderness is noted at the medial joint line. 
The x-rays demonstrated moderate narrowing of the medial compartment of the left knee, probably about 50%. 
The magnetic resonance imaging (MRI) also demonstrated tricompartmental chondromalacia with scattered 
partial to full thickness cartilage loss. There are limited large-scale, long-term references showing the safety 
and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the requested knee arthroscopy is not medically reasonable and 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 knee arthroscopy services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (12013) provided August 30, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and 
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, we have confirmed that code 12013 
is a column II code to column I code 99285. 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 physician services (12013) provided August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population. 
 
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 knee scooter. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no specific evidence documented of why patient requires a knee scooter. A knee 
scooter is generally considered medical equipment of convenience without a specific indication. 
 
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 knee scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (A4520, A9286, and A4927). 
 
You asked the Plan to pre-approve incontinence supplies. You say that incontinence supplies are medically 
necessary for you. The Plan denied your request. The Plan says the incontinence supplies are not medically 
necessary for your condition. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A4520, 
A9286, and A4927).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal laminectomy (back surgery) for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not indicate that the enrollee was evaluated by the operating 
surgeon. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical records do not show any evaluation and decision-making note from a spinal surgeon. The 
records do not support the need for spinal surgery 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal laminectomy (back surgery) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on May 17, 
2021, and November 8, 2021 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $40 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $21.62 copayment for the laboratory services provided on May 17, 2021, which 
is less than the standard $40. You have also been asked to pay a $40 copayment for the laboratory services 
provided on November 8, 2021. 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 laboratory services 
provided on May 17, 2021, and November 8, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography (93313) provided on September 15, 2021. 
  You asked the Plan to pay for echocardiography (93313). You say that modifier 59 was billed to indicate this 
procedure was separate from another procedure on the same date of service. You say that CPT ode 93313 is a 
separately reimbursable code and the claim should be reprocessed for payment. The Plan denied your request. 
The Plan says CPT code 93313 is included in CPT code 00567 and cannot be separately reimbursed. 
 
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 93313 is a column II code to column I code 00567; however, 93313 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for echocardiography (93313). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report does not support this procedure as a distinct procedural service. Therefore, CPT code 93313 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of echocardiography (93313) have not been met. Therefore, we decided that the 
Plan does not have to pay for echocardiography (93313) provided on September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo for the enrollee. 
 
You asked the Plan to pre-approve Ziextenzo. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Ziextenzo. Our reviewer says that 
Ziextenzo is not medically reasonable and necessary. The enrollee has not tried and failed Neulasta 
(pegfilgrastim), Fulphila (pegfilgrastim-jmdb) or Udenyca (pegfilgrastimcbqv). The Plan's required drugs 
would not likely be less effective and/or likely have adverse effects for the enrollee. The standard and 
biosimiliars are likely to be as effective. Our physician reviewer found that the enrollee's condition does not 
meet step therapy criteria for Ziextenzo. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ziextenzo for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90792) provided 
September 14, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 90792 is not supported in the medical record. Specifically a secondary only diagnosis 
code was listed as the primary diagnosis. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does 
not have to pay for outpatient mental health services (90792) provided September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to a Long-Term Acute Care Hospital (LTACH). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with dyspnea in the setting of aspiration pneumonia. The 
record indicates that the enrollee requires ongoing acute care services. 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. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (72132) 
provided on February 18, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $180 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $180 copayment for the CT scan. CT scans fall within the Outpatient diagnostic 
tests and therapeutic services and supplies 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 a computed tomography (CT) scan (72132) provided on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myoelectric prosthetic arm. 
 
You asked the Plan to pre-approve the requested item. You say that you require the device to continue your 
lifestyle. The Plan denied your request. The Plan says there is no documented reason why you cannot use a 
body-powered device. 
 
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 requested item. Our physician 
reviewer found that you have a past medical history significant for congenital absence of right hand and digits. 
Authorization for myoelectric prosthetic arm has been requested. The clinical documentation does not support 
the need for a myoelectric prosthetic arm. The reasoning listed for wanting to use something other than a 
"swimmers" prosthesis is for gardening. Additionally, it is documented that you did not use a previous myo-
electric prosthesis due to the weight and complexity. Therefore, the requested prosthesis 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 item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a myoelectric prosthetic arm.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from May 
9, 2022, forward. 
 
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that the continuation 
of inpatient psychiatric care is medically necessary. The Plan denied your request. The Plan says there is no 
medical need for inpatient psychiatric care from May 9, 2022, forward. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continuation of inpatient psychiatric 
care. Our reviewer says that the requested continuation of inpatient psychiatric care is not medically reasonable 
and necessary. Our physician reviewer found that you are a 78-year-old female who was admitted to the acute 
inpatient psychiatric hospitalization on May 5, 2022, with Major Neurocognitive Disorder, Unspecified with 
Behavioral Disturbance. Based upon review the records provided it was not expected that you would improve 
in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation, 
auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to 
safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as you did not have 
dangerousness to self or others and were compliant with your treatment. 
 
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 continuation of inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from May 9, 
2022, forward.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
with supervision with handheld assistance and no assistive device and is supervision level for transfers. 
Provided records do not document a significant decline in the enrollees functional status to necessitate daily 
inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records do not document that services in the long-term care facility on a part 
time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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. The Plan denied your request. The Plan says this 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitation care. 
Our reviewer also found that while the enrollee may benefit from physical therapy, speech therapy, and 
occupational therapy, his rehabilitation needs can be addressed at a low intensity alternate setting, such as in a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.