Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure provides a treatment gap 
for those that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says the requested 
procedure is not medically 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental. Therefore, the reviewer found 
that an Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the 
temporomandibular joint(s) provided on June 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an out-of-network MRI. You say that this service was pre-approved and should 
be paid. The Plan denied your request. The Plan says this service was not pre-approved to be performed by this 
out-of-network provider. The authorization provided was for a specified network provider. 
 
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 magnetic resonance imaging (MRI) of the 
temporomandibular joint(s) provided on June 7, 2022, by an out-of-network (OON) provider.
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 want to go to a specific rehabilitation center for 
your therapy. The Plan denied your request. The Plan says the IRF care is not medically necessary, and your 
needs can be met at a lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have chronic functional loss and have been deconditioned following the additional burden of chronic illness. You have rehabilitation needs consistent with chronic illness and recent 
acute illness. This level of rehabilitation needs is routinely addressed at a level of care other than an IRF. You 
do not require intensive rehabilitation and do not require frequent physiatry oversight. 
 
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 proton beam therapy (77523). 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 proton beam therapy. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that to date there are no compelling data to suggest that proton beam therapy is superior to or 
more beneficial than approaches such as intensity-modulated radiation therapy (IMRT)/image-guided radiation 
therapy (IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam 
therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77523).
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 medically necessary. The Plan 
denied your request. The Plan says an intensive rehabilitation program 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 enrollee does not require treatment by multiple therapies. While the medical 
records do support a need for physical and 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 76882. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76882 is bundled into payment for code 93971. 
 
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 76882 
is a column II code to column I code 93971. 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 76882 billed for date of service April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary, the services the enrollee needs can be provided 
safely in other settings, for example, a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 acute 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. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection is not 
medically necessary and does not meet the Medicare LCD 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 in this case. Our physician reviewer 
found that the provider documented that the enrollee has axial low back pain consistent with painful facet joint 
arthrosis left L4-5 vs L3-4 vs L5-S1 s/p left L3,4,5 medial branch neurotomy. Since the enrollee's last visit, he 
has had progressive pain now involving his right posterior thigh and paresthesia of his lateral leg. The provider 
has requested a therapeutic right L5 and S1 selective nerve root blocks to provide a percentage of improvement 
in pain. Selective Nerve Root Block (SNRB) - A diagnostic injection of contrast (absent allergy to contrast) of 
a single nerve root to assist with surgical planning, followed by the introduction of a local anesthetic by 
inserting a needle into the neuroforamen under fluoroscopic or computed tomography (CT) guidance. SNRB's 
are erroneously referred to as a Transforaminal Epidural Steroid Injection (TFESI), although technically, 
SNRB's involve the introduction of anesthetic only used for diagnostic purposes. SNRBs are erroneously 
referred to as a Transforaminal Epidural Steroid Injection (TFESI), although technically SNRBs involve the 
introduction of anesthetic only and are used for diagnostic purposes. In this case, the request is for a therapeutic 
SNRB right L5 - S1 selective nerve root block. The review has determined that the requested TFESI 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377), a 
small forearm pad (K0108) and a hand pad (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that not only do you qualify for this chair, 
but it also shows that you need it to prevent further injury which can cause serious and expensive medical 
problems. The Plan denied your request. The Plan says although there are three approved power options on this 
wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options 
through the joystick. The Plan also says the forearm pad is already included in the approved E1007 power tilt 
and recline and the hand pad cannot be requested separately. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The records show that although there are three approved power options on this wheelchair, there is not a 
medical need to control these power options through the joystick. The records also show the forearm pad, and 
the hand pad are already included in the approved wheelchair accessories. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377), a small forearm pad 
(K0108) and a hand pad (K0108).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99284) 
provided to the enrollee on July 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim is downcoded to CPT 99283. 
 
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 99284 is [*****enter CPT Codebook definition*****]. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, there were no 
presenting problems of high severity requiring urgent evaluation by the physician. The review has determined 
that the records did not support medical decision making of moderate complexity in this case. The records did 
not support that the presenting problems were high severity, posing an immediate significant threat to life or 
function.  
We looked at this coder'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 pay for emergency department services (procedure code 99284) provided to the enrollee on July 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued continuous positive airway pressure (CPAP) 
and supplies. 
 
You asked the Plan to pre-approve continued CPAP and supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested continued CPAP. 
 
The Plan follows Medicare rules. Medicare rules say that continued CPAP is only covered when adherence to 
therapy criteria has been 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 continued CPAP and supplies. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found you have obstructive sleep apnea and were using CPAP with 
excellent adherence in late 2021. But data from March to June 2022 showed very little use, only 3% of nights 
with at least four hours of usage, which does not meet Medicare criteria of 70%. There is no record of attempts 
to address the compliance issue. Therefore, you do not meet criteria for the requested continued use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued CPAP and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued continuous positive airway pressure (CPAP) and supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, chest; single view (code 71035) 
provided on August 4, 2022. 
 
You asked the Plan to pay for a radiologic examination, chest; single view. The Plan denied your request. The 
Plan says the services were not authorized. 
 
The Plan contract covers x-ray services. The Plan says prior authorization may be required and is the 
responsibility of the provider. 
 
We looked at the file and the Plans rules. The file shows that the services were not authorized. Based on this 
information, we decided that Medicare rules for coverage of a radiologic examination, chest; single view have 
not been met. Therefore, we decided that the Plan does not have to pay for a radiologic examination, chest; 
single view (code 71035) provided on August 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) provided to the enrollee on May 23, 
2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported with the appropriate diagnosis code. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this service is allowed providing the patient is 65-75 years old and has a history of smoking at least 
100 cigarettes in their lifetime, has a family history of abdominal aortic aneurysm, or other factors placing the 
patient at increased risk. Although the enrollee's age does qualify, none of the other requirements have been 
met. The exam was not justified. 
 
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 pay for an ultrasound, abdominal aorta, real time with image documentation, screening study for 
abdominal aortic aneurysm (AAA) provided to the enrollee on May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that these orthotics have helped you for over 9 years 
and you believe you would have trouble with another type of orthotic. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the requested foot orthotics are not an integral part of a leg brace. Although you have 
diabetes, the particular orthotics you have requested are not classified as diabetic footwear. Please contact the 
Plan for more information about diabetic footwear that may meet your needs. Therefore, we decided that the 
Plan does not have to pre-approve foot orthotics.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 13, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the patient was enrolled in a federal hospice program during the time the services were rendered. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 13, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on May 4, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan 
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network 
provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
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 the office services provided on May 4, 2022, by an 
out-of-network provider.