Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from March 18, 
2022 onward. 
 
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. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 enrollee was admitted to the 
hospital on March 4, 2022 with major depressive disorder, alcohol dependence, and cocaine dependence. Based 
on the submitted records, it is not expected that he will improve in a reasonable period of time beyond the dates 
in question, as he is not showing any dangerousness to self or others and has no aggressive behaviors. He is not 
having auditory or visual hallucinations. It does not appear that active treatment is taking place beyond the 
dates in question. Continued services are not needed to improve his condition or for the purpose of diagnosis. 
The continued services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services from March 18, 2022 onward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom knee brace L1832. 
 
You asked the Plan to pre-approve a custom knee brace. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there is no documentation as to why a custom fabricated knee is medically 
necessary over a prefabricated orthosis. 
 
The Plan follows Medicare rules. Medicare rules say that if a custom fabricated orthosis is provided but the 
medical record does not document why that item is medically necessary instead of a prefabricated orthosis, the 
custom fabricated orthosis will be denied as not 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 a custom knee brace. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is no documentation of knee 
joint laxity or deformity of the leg or knee, a size of the thigh or calf requiring a custom orthosis or decreased 
muscle mass upon which to suspend a prefabricated orthosis. 
 
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 custom knee brace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a custom knee brace L1832.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1/BRCA2 genetic testing. 
 
You asked the Plan to pre-approve BRCA1/BRCA2 genetic testing. You say that the records provided support 
the need for the requested testing. The Plan denied your request. The Plan says the requested genetic testing is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA genetic testing is covered for certain clinical 
indications.  
 
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 BRCA1/BRCA2 genetic testing. Our 
reviewer says that the criteria for coverage have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRCA1/BRCA2 genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve BRCA1/BRCA2 genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON second opinion. You say that you were told by a provider that 
your lumps are cysts and not tumors and that you do not have cancer. You say that you were told you would die 
within a year and after two years you are still okay. You say that you don't trust the Plan's network providers 
and feel you are being lied to about your cancer diagnosis. You say that you do not want to move forward with 
treatment and feel the diagnosis is incorrect. You say that you need an OON referral to determine if the 
diagnosis is incorrect. The Plan denied your request. The Plan says they have multiple network providers who 
you can see for a second opinion. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
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 
service is medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do have documented skilled therapy needs. You are functioning below your reported baseline. The 
documentation does not yet show that you have reached a new, lower, level of function. Daily skilled services 
are required to establish a maintenance program or to prevent deterioration of your condition. 
 
 
  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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on November 18, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the level of service. The Plan denied your request. The Plan says rules for payment have not been met 
because the procedure code at issue is inclusive to another billed code. 
 
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 70450 
is a column II code to column I code 70496. 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 a computed tomography (CT) scan of the head or brain (70450) 
provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive services provided on February 17, 2020. 
 
You asked the Plan to pay for the preventive services. You say that you have no other coverage, and the 
doctors need to be paid. The Plan denied your request. The Plan says the recoupment will be upheld until a 
primary Explanation of Benefits is received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers.  
  Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill 
directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the 
primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary 
insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
primary insurance carrier for the Explanation of Benefits. As the secondary insurer, the Plan cannot be held 
responsible for the preventive services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the preventive services provided on February 17, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections. 
 
You asked the Plan to pre-approve platelet rich plasma injections. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve platelet rich plasma injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided and the Medicare-approved major 
drug compendia there is no documentation that the platelet rich plasma injections at issue in this case meet 
Medicare criteria for medically reasonable and necessary. Drugdex/Micromedex carries a strong 
recommendation against use of platelet-rich plasma for osteoarthritis of the knee. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of platelet rich plasma injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve platelet rich plasma injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for community use only. 
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that you have a mobility deficit that impairs MRADLs in the home. There is no evidence that 
there is a mobility deficit that would not be ameliorated by a walker, cane, or manual wheelchair. There is no 
detailed musculoskeletal or neuromuscular exam that indicates that you are unable to use a cane, walker, or 
manual wheelchair.  The home assessment does not support that the requested K0800 will be able to safely maneuver in the home 
and access rooms for MRADL participation. The documentation does not support that the wheelchair will 
significantly improve your ability to participate in MRADLs, and that you will use it in the home. A 2/25/22 
home assessment states that you want a scooter for outdoor use, and that it will not in the home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided minimally invasive lumbar 
decompression (MILD). 
 
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 enrollee has low back pain with 
spinal stenosis. The requested MILD procedure is considered experimental in nature for spinal stenosis. More 
research is needed to support safety and efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous image-guided minimally invasive lumbar decompression (MILD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly. 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 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 provided on August 11, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a femur 
fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 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. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and a portable gaseous oxygen 
system for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item may only be approved if it is medically necessary. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found home oxygen is 
considered not medically necessary because Medicare coverage requirements are not met. The enrollee's 
assessment for oxygen need took place as an inpatient in June 2021.  Medicare requires that qualifying 
oxygenation measurements be done within 30 days prior to the oxygen order. The enrollee will need updated 
oxygenation data, either ABG or SpO2, at rest and with exercise, to establish that the need is current. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator and a portable gaseous oxygen system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because this is not a late nor last resort for 
treatment of the enrollee's pain. The Plan states there are other options that have yet to be tried. 
 
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 service. Our physician reviewer 
found not all treatment options have been tried. Stimulator trial not needed 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous implantation of neurostimulator electrode array, epidural (CPT code 
63650).