Persius/hicric huggingface dataset:
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 services are medically necessary. The 
Plan denied your request. The Plan says the enrollee's medical needs are being met 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. The health plan has approved ongoing care 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of an intraosseous basivertebral 
nerve, including all imaging guidance. 
 
You asked the Plan to pre-approve thermal destruction of an intraosseous basivertebral nerve, including all 
imaging guidance. You say that this procedure is medically necessary. The Plan denied your request. The Plan 
says this 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 thermal destruction of an intraosseous 
basivertebral nerve, including all imaging guidance. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the lumbar magnetic 
resonance imaging (MRI) shows disc hernaition and stenosis. There is a diagnosis/cause for the back pain other than disc degeneration.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of an intraosseous basivertebral nerve, including all imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal 
destruction of an intraosseous basivertebral nerve, including all imaging guidance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous laser ablation with sclerotherapy. 
 You asked the Plan to pre-approve endovenous laser ablation with sclerotherapy. You say that these services 
are medically necessary. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous laser ablation with sclerotherapy are 
coverable under the following conditions when the patient has undergone a 3-month trial and failure of 
conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance 
of prolonged immobility where appropriate.  
  
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 endovenous laser ablation with 
sclerotherapy. Our reviewer says that endovenous laser ablation with sclerotherapy is not medically necessary. 
Our physician reviewer found in this case, the patients complaint is of nocturnal right leg pain that began 
approximately 1 month prior to her visit. As the symptoms have only been present for one month, the 
documentation would support the health plans position that a 3-month trial of conservative efforts has not been 
completed.  No other significant symptoms are described including in the left leg.  The resulting initial request 
for coverage was for 15 procedures including endovenous ablation presumably of the right great saphenous 
vein as well as two units of stab phlebectomy and 12 units of sclerotherapy involving both legs.  Additionally, 
as numerous procedures are being requested including for the relatively asymptomatic left leg, coverage cannot 
be recommended of treatments without more clarity of a symptom focused plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous laser ablation with sclerotherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve endovenous laser ablation with sclerotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac implantable device (33225). 
 
You asked the Plan to pre-approve a cardiac implantable device. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of this 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 a cardiac implantable device. 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 a history of atrial fibrillation with previous AV node 
ablation and pacemaker implant. At issue is the medical necessity of implanting a CRT-P system in this 
enrollee. Echocardiogram has showed preserved ejection fraction of 60% and clinical improvement with 
medical therapy per his last office visit. As such, 2021 AHA/ACC guidelines do not recommend CRT-P in 
such enrollees. In summary, there is insufficient documentation to support the medical necessity for placement 
of a bi-ventricular pacemaker. 
 
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 cardiac implantable device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cardiac implantable device (33225).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided from September 28, 2022, 
through October 5, 2022, billed with codes 97110 and 97530. 
 
You asked the Plan to pay for the therapy services as billed. You say that the services provided were medically 
necessary and should be paid. The Plan denied your request. The Plan says the codes are not supported by the 
documentation. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The 
definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities 
to improve functional performance), each 15 minutes.  
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 therapy services as billed. Our reviewer says that the 
documentation does not support the billed services. Our reviewer found medical records do not support the use 
of procedure code 97110 as there is no information in the report that supports therapeutic procedures being 
done. Medical records do not support the use of procedure code 97530 as the enrollee activity note does not go 
into detail as to what the enrollee contact was and, therefore, the code cannot be reviewed and 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 the therapy services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the therapy services provided from September 28, 2022, through October 5, 2022, 
billed with codes 97110 and 97530.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient spine surgery. 
 
You asked the Plan to pre-approve inpatient spine surgery. You say that you have provided medical records to 
support the need for this surgery. The Plan denied your request. The Plan says the patient has not had a 
sufficient trial and failure of conservative therapy or magnetic resonance imaging (MRI). 
 
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 inpatient spine surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not show imaging studies with instability or stenosis. There is no 
documentation of a recent 12 week trial of conservative management including physical therapy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient spine surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient spine surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or 
pharmacologic) and/or redistribution and/or rest reinjection (78452). 
 
You asked the Plan to pre-approve SPECT testing. You say that you need to do the stress test in order to check 
if your heart would be strong enough for a surgery. The Plan denied your request. The Plan says under 
Medicare guidelines, your request is not medically necessary because your records show you do not have evidence of cardiac ischemia and prior testing demonstrated normal left ventricular function, and your 
cardiologist stated you do not need additional cardiac appointments. 
 
The Plan follows Medicare rules. Medicare rules say that SPECT is covered when medically reasonable and 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SPECT testing. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the records indicate that your 
cardiologist reviewed previous stress test result, which was negative. Your cardiologist also reviewed your 
echocardiogram, indicating that you are at low risk for surgery and found there was no need for further cardiac 
follow-up. There is no evidence provided that would support the need for radionuclide stress testing at this 
time. In summary, there is insufficient documentation to support the medical necessity for the requested cardiac 
stress testing in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, 
qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional 
quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or 
redistribution and/or rest reinjection (78452).
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the admission to an IRF 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 that you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 
April 18, 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 Current Procedural Terminology (CPT) code 99223 remains 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 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 limited information has been 
provided about the present illness. The medical decision making is not of high complexity. 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 April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI. You say that the requested MRI is medically necessary. The Plan 
denied your request. The Plan says that the MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the enrollee recently had sudden onset of 
right leg pain but at the encounter on March 30, 2023, the pain had resolved and physical exam at that time was 
normal with no red flags.  Physical therapy has not been done.  The medical necessity of MRI lumbar spine has 
not been established in the records provided since according to the notes the right leg pain had resolved as of 
March 30, 2023, and no neurological deficits are present. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI of the lumbar spine.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 19 additional physical therapy (PT) visits 
 
You asked the Plan to pre-approve the therapy services. You say that additional PT is needed. The Plan denied 
your request. The Plan says this request is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have had extensive prior therapy and the documentation does not 
reveal that you require the ongoing unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. The therapy note 
indicate you have improved with gait training showing improved balance. You have noted increased strength 
and proper technique with sit-to-stand transfers. You have had instruction in a home exercise program.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 19 additional physical therapy (PT) visits
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that you would prefer using proton 
beam therapy versus going through chemotherapy to treat your cancer. The Plan denied your request. The Plan 
says this treatment 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 proton beam radiation therapy. 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 clear evidence that proton beam therapy for prostate cancer 
offers any clinical advantage over other forms of treatment. Clinical trials are necessary to establish a possible 
advantage of this expensive therapy. Nothing in the medical records suggests that standard dosimetric constraints cannot be met with a non-proton based treatment, and it is not plausible that proton therapy would 
be needed to meet constraints. 
 
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 radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA). 
 
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 PTA is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee is documented to have 
good functional capacity without complaints. He is documented on more than one occasion to have good distal 
pedal pulses. There is no documentation suggesting lifestyle limiting claudication or any sign of limb threat. It 
appears from the records that he had an incidental finding of occlusive disease in the left iliac and superficial 
femoral arteries. No ankle-brachial index (ABI) is provided. The requested PTA is not reasonable or medically 
necessary based on the submitted records. 
 
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 percutaneous transluminal angioplasty (PTA).