Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (0312U, 83516) provided on May 23, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that these services were medically necessary and are 
supported as in the medical record. The Plan denied your request. The Plan says that code 83516 is a duplicate 
of another service which has already been paid, and code 0312U does not meet requirements for coverage. 
 
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 explanation for the denial of these 
services, and this reasoning has not been supported with evidence. In addition, the Plan has provided no 
documentation to support that code 83516 has already been paid in a duplicate claim. The Plan has not 
substantiated their denial in this case. Therefore, we decided that the Plan has to pay for laboratory testing 
(0312U, 83516) provided on May 23, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the clinical information provided supports the 
need for the requested PET scan. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the service 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominoplasty. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee underwent gastric 
bypass surgery on October 27, 2022 and lost a significant amount of weight. The available documentation, 
including photographs, does not support that she has chronic intertrigo that consistently recurs or remains 
refractory to appropriate medical therapy such as topical antifungals, corticosteroids, or antibiotics over a 
period of three months. The abdominoplasty is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an abdominoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty. 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 total hip arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested total hip arthroplasty, 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 a total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need additional rehabilitation to learn how to 
function with your left shoulder being broken. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgery. 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that this 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 the 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 the vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R Interspinous 
device. 
 
You asked the Plan to pre-approve the Minuteman G3R Interspinous device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Minuteman G3R Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the minuteman device is experimental in spine surgery. 
 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 Minuteman G3R Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of the Minuteman G3R Interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the requested CGM is medically 
necessary to prevent diabetes. The Plan denied your request. The Plan says that the coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM and 
supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the current evidence based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of the Superion spacer for this enrollees medical condition. The services are 
therefore not reasonable or medically necessary at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is considered investigational. More research is needed to show 
safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the office setting POS code. 
The records do not support that the services were provided in an office setting. Therefore, we decided that the 
Plan does not have to pay for the services provided on November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested CGM is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and do not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
CGM and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided from March 30, 2022, through April 1, 2022, billed with code 99233. 
 
You asked the Plan to pay for the EM services as billed. You say that the code used in this case is supported. 
The Plan denied your request. The Plan says the record does not support the EM code 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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 EM services as billed. Our reviewer says 
that the EM services as billed are not supported by the records. Our reviewer found the enrollee is a 71-year-
old female who had hospital services from 3/30/22 to 4/1/22. The provided records described the enrollee as 
presenting with weakness which she had been experiencing for one month since having COVID. She denied 
other symptoms or loss of consciousness. Physical findings were normal without strength or sensory testing 
documented. Workup was unremarkable except for elevated troponin for which she was treated with heparin 
and fluids. Heparin was then discontinued, and the enrollee was feeling better throughout course of 
hospitalization. Based on the provided documentation, there was no evidence of a detailed history or physical 
examination, and there was no indication of medical decision-making of high complexity.  
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient evaluation and management (EM) services provided from March 30, 
2022, through April 1, 2022, billed with code 99233.
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 enrollee will benefit from the 
services for their care needs to help prevent readmission to short term acute care hospitals. The Plan denied 
your request. The Plan says the enrollee is receiving the appropriate care needed in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to require additional short-term acute care services that can 
safely be provided at the current facility until more stable and appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility. 
Completion of treatment at the current facility is 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99497, 99239) provided on January 25, 2022, 
and January 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 99497 is "Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate". The CPT Code Manual definition of code 99239 is "Hospital 
discharge day management; more than 30 minutes". 
 We find that CPT code 99497 is not supported in the medical record. Specifically, the records do not document 
the time spent providing this service. We also find that CPT code 99239 is not supported in the medical record. 
The records do not show that more than 30 minutes of hospital discharge management services were provided 
on the date of service in question. 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 the services 
(99497, 99239) provided on January 25, 2022, and January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abatacept infusion provided on October 10, 2022. 
 
You asked the Plan to pay for the abatacept infusion. You say that the medical records support this service. 
You also say that this was medically necessary for the enrollee. The Plan denied your request. The Plan says 
the criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the abatacept infusion have not been met. Therefore, we decided that the Plan does not have to pay 
for the abatacept infusion provided on October 10, 2022.