Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an x-ray (D0270), core buildup for teeth #2, 4, 31 
(D2950), and deep medicated filling on teeth #4 and 31 (D3120). 
 
You asked the Plan to pre-approve an x-ray, core buildup for teeth #2, 4, 31, and deep medicated filling on 
teeth #4 and 31. You say that the services are necessary. The Plan denied your request. The Plan says the 
requested x-ray benefit has been exhausted. The other requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an x-
ray (D0270), core buildup for teeth #2, 4, 31 (D2950), and deep medicated filling on teeth #4 and 31 (D3120).
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 for the enrollee 
to get back their mobility and become self-reliable again. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in another setting such as, a skilled nursing facility, home 
with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for a post stabilizations inpatient stay provided on December 6, 2022, to 
December 28, 2022. 
 
You asked the Plan to pay for a post stabilizations inpatient stay. You say that this inpatient stay was medically 
necessary. The Plan denied your request. The Plan says that this inpatient stay has been correctly denied due to 
medical necessity. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 a post stabilizations inpatient stay. Our 
reviewer says that this inpatient stay was medically necessary. Our physician reviewer found the enrollee was 
considered medically stable for transfer to a SNF on December 28, 2022. 
 
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 post stabilizations inpatient stay have been met. Therefore, we decided that 
the Plan has to pay for a post stabilizations inpatient stay provided on December 6, 2022, to December 28, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) with 6 
fractions. 
 
You asked the Plan to pre-approve IMRT. You say that it is medically necessary. The Plan denied your request. 
The Plan says the reason this request cannot be approved is because guidelines do not support the routine use of 
the requested type of treatment (therapy) for your cancer type. It has not been shown that your cancer type has 
responded well to the requested type of treatment. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has high volume metastatic prostate metastatic castrate resistant prostate cancer to 
the bones and lymph nodes (stage T2cN1M1). Current management is with ADT and Xgeva. Most recent PSA 
was 1.27 ng/mL on December 27, 2022. The enrollee has received 800 cGy in a single fraction to the right 
femur. IMRT in 6 fractions given weekly to 36 Gy to the prostate is not medically reasonable and necessary in 
this case. According to the most recent AUA Guidelines, prostate radiation is not indicated for patients with 
high volume metastatic castrate resistant prostate cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation therapy (IMRT) with 6 fractions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
22, 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 records do not support the services 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 the documented physical 
examination is not comprehensive. The documentation does not note a treatment plan. As such, the billing of 
CPT 99223 is not supported. 
 
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 initial hospital care (procedure code 99223) rendered on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Myopro orthotic device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colectomy, partial; with anastomosis rendered on June 27, 
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 procedure code 44140-62 is not supported by the medical records submitted. 
 
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 44140 is "Colectomy, partial; with anastomosis." 
 
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 the operative report does not 
describe partial colectomy with anastomosis. In this case, this procedure cannot be verified as performed. 
 
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 colectomy, partial; with anastomosis rendered on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair itself and the other requested 
items/accessories (K0856, E0955, E1002, E1012, E1028, E2607, E2359, E2613). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not need a group 3 power wheelchair with the requested power 
options. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the enrollee does not have diagnostic criteria as the need is not related to neuromuscular disease or 
congenital deformity nor is the enrollee at high risk for skin breakdown, use a catheter or have spasticity 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power wheelchair itself and the other requested items/accessories (K0856, E0955, E1002, 
E1012, E1028, E2607, E2359, E2613).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one (1) additional skilled nursing visit (G0299). 
 You asked the Plan to pre-approve home health 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. 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
has a diagnosis of multiple sclerosis. Provided records do not document any acute or unstable medical 
conditions or changes in medication or treatment which would necessitate any further skilled nursing visits 
beyond what have already been approved. Records document the enrollee has been educated on his disease 
process, home safety measures and his medications. No medical visit notes from the enrollee's treating 
physician are provided documenting an order or need for additional skilled nursing services. Records do not 
document the need for intravenous medications, new tube feeding, or ostomy care or daily complex wound 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve one (1) additional skilled nursing visit (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid (64483) 
and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural (64484). 
 
 
 
 You asked the Plan to pre-approve injections. You say that the enrollee has decreased mobility due to pain. He 
has received 80% improvement for 2 weeks after the first injection. You are requesting a second injection. The 
Plan denied your request. The Plan says the request is not medically necessary because the records indicate that 
the enrollee had >50% pain relief after his March 9, 2023, injection, but this was less than 3 months ago. The 
submitted records do not document why a second injection earlier than 3 months would be 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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found repeat ESI when the first injection directly and significantly provided improvement of the 
condition being treated may be considered medically reasonable and necessary when the medical record 
documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from 
baseline using SAME scale* for at least three months. The request was made after 2 weeks; therefore, the 
request does NOT meet the LCD criteria and is deemed 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid (64483) and injection(s), anesthetic agent(s) 
and/or steroid; transforaminal epidural (64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound image guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT. You say that the medial records provided support that the 
requested treatment is medically necessary. The Plan denied your request. The Plan says US-IGRT is not 
medically necessary for superficial radiation therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve US-IGRT. Our reviewer says that US-
IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer found usually 
IGRT is used when critical structures are abutting or in close proximity to the target that is being treated to high 
doses. This situation does not apply to this enrollee for which the target lesion can be seen on the skin to assist 
in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. Using ultrasound on a daily basis is not unreasonable to offer but is not necessary. The device 
itself is approved by the Food and Drug Administration (FDA) for use with ultrasound. However, that in and of 
itself does not mean that daily imaging is necessary, but simply that the device was designed to incorporate this 
functionality. Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has 
not been established by published data or supported by consensus guidelines (many of which recommend 
against treatment with these devices in general) is not 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 US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound image guided radiation therapy (US-IGRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 75710. You say that this service is supported as billed and should 
be paid separately. The Plan denied your request. The Plan says the payment for code 75710 is included in the 
payment for codes 37226 and 37228. Although this service was billed with a modifier for separate payment, the 
medical records do not support that this modifier was used appropriately. 
 
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 75710 
is a column II code to column I codes 37226 and 37228; however, 75710 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 procedure code 75710. Our reviewer says that modifier 59 
for this service cannot be verified. Our reviewer found the provider reported a radiological service in the same 
anatomical area as the intervention was performed, and therefore this service would be included in the primary 
procedures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 75710 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 75710 billed for date of service July 26, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. 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. 
 
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 Injectafer. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says the request 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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care or at a lower level of care. All medically necessary 
care is being provided in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.