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

 
We decided that the Plan has to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483). 
 
You asked the Plan to pre-approve a repeat TFESI. You say that the enrollee needs this service in order to 
improve their condition. The Plan denied your request. The Plan says that the requested service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat TFESI. Our reviewer says that 
a repeat TFESI is medically necessary. Our physician reviewer found the provided documentation indicates 
that the enrollee had 50% pain relief for more than three months. Therefore, the reviewer found that a repeat 
TFESI is 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 a repeat TFESI have been met. Therefore, we decided that the Plan has to pre-
approve a repeat transforaminal epidural steroid injection (TFESI) (64483).   
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 stereoscopic x-ray guidance for localization of target 
volume for the delivery of radiation therapy (G6002), and guidance for localization of target volume for 
delivery of radiation treatment (77387). 
 
You asked the Plan to pre-approve image guided radiation therapy (IGRT). You say that the requested 
treatment is necessary for the enrollee due to the location of each lesion, current comorbidities and 
medications. The Plan denied your request. The Plan says the requested 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 image guided radiation therapy (IGRT). 
Our reviewer says that the requested IGRT is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient objective clinical evidence in the medical literature to support these services tin this setting. Therefore, the reviewer found that image guided radiation therapy 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 image guided radiation therapy (IGRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve stereoscopic x-ray guidance for localization of target 
volume for the delivery of radiation therapy (G6002), and guidance for localization of target volume for 
delivery of radiation treatment (77387).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on March 
21, 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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 96372, 99283, 99284 and J1885 is not supported in the medical record. Specifically, it 
is inappropriate to report these services without condition code G0. 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 room services provided to the enrollee on March 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) reader. 
 
You asked the Plan to pre-approve a CGM reader. You say that the enrollee types all day at his job and cannot 
continue sticking his fingers. The enrollee also has a fear of needles. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for approval of the requested CGM reader. 
 
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 or 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 
reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that the item is necessary. 
The Plan denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental removal of mandibular torus (D7473), parenteral 
drugs (D9610), and dental sedation (D9239 and D9243). 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says this request is not covered by the Plan. 
 
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. The Plan covers certain dental 
services when the services are medically necessary and reasonable. However, the Plan does not cover dental 
codes D7473 and D9610. 
 
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 dental services. Our reviewer says that 
the dental sedation services requested are not medically necessary. Our physician reviewer found this 
procedure is normally performed under local anesthesia. There is no indication that the enrollee has medical 
issues which would require intravenous sedation/analgesia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Although removal of mandibular torus 
(D7473) and parenteral drugs (D9610) may be appropriate for you, these services are not covered by the Plans 
dental benefits. Therefore, we decided that the Plan does not have to pre-approve dental removal of mandibular 
torus (D7473), parenteral drugs (D9610), and dental sedation (D9239 and D9243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a continuous glucose monitor (CGM). 
 
You asked the Plan to provide a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
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. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
provide a continuous glucose monitor (CGM).
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 the enrollee will not regain their strength without 
more physical therapy and around the clock care. The Plan denied your request. The Plan says that the 
admission to a SNF 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 the documentation does not show that the enrollee requires daily skilled services. 
The provided records do not document a significant decline in the enrollees functional status compared to his 
recent baseline to necessitate daily inpatient skilled therapy services. There is no documentation that the 
enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. The records support 
that services in the home with home health care or in a long-term care facility on a part time basis are 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 are appealing the denial for the admission to an 
IRF. 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 the enrollee does 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 the enrollee 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: 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 are appealing with supporting records. 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee can receive further 
services at a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulator (TENS) unit leads 
provided on August 4, 2022. 
 
You asked the Plan to pay for TENS supplies. You say that this claim was billed in accordance with policy. 
The Plan denied your request. The Plan says there is no evidence to support the 
ordering provider ordered these supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery. The delivery form does not include 
evidence of delivery of the specific items billed on this claim to the enrollee. The physician order and the date 
of delivery are from different calendar years. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
transcutaneous electrical nerve stimulator (TENS) unit leads provided on August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay an additional amount for inpatient hospital services provided on January 
27, 2022, through February 26, 2022. 
 
You asked the Plan to pay an additional amount for inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation submitted does not support the services billed. 
 
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 documentation submitted does not include any medical records. 
Of note, the Plan clearly indicates that medical records were used to make their reconsideration decision. It is 
the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not 
been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay an additional 
amount for inpatient hospital services provided on January 27, 2022, through February 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glycosylated hemoglobin (A1C) testing (83036) provided on 
July 14, 2022. 
 
You asked the Plan to pay for hemoglobin testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this testing was not medically necessary and is considered a non-covered 
screening in this case. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The rules say that it is not considered reasonable and 
necessary to perform glycated hemoglobin tests to diagnose diabetes. 
 
The record shows that the enrollee does not have a diagnosis of diabetes. Therefore, the test at issue in this 
appeal, hemoglobin testing, was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for glycosylated 
hemoglobin (A1C) testing (83036) provided on July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on June 20, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the medical records do 
not include evidence that the provider ordered/referred the DME for the member. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not show that the treating physician intended that the enrollee use a TENS unit and 
supplies. The record shows that the Plan made attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided on June 
20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine culture and sensitivity testing (87077, 87088, 
87186) provided on August 4, 2022. 
 You asked the Plan to pay for the urine culture and sensitivity testing. You say that this diagnosis code and 
charges are supported in the medical records provided. The Plan denied your request. The Plan says this claim 
was submitted with only a diagnosis code of Z5.93 (problems related to living in residential institution) which 
indicates that this testing was done for screening purposes and therefore is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the urine culture and sensitivity testing, was requested solely for screening 
purposes based on the diagnosis reported on this claim. Medicare does not cover this test solely for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the urine culture and sensitivity testing 
(87077, 87088, 87186) provided on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223. 
 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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82043, 82570) provided on October 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical records. 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, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (82043, 82570) provided on October 4, 2021.