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

 
We decided that the Plan does not have to pay for the anesthesia services coded as 00562 provided on August 
25, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 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 00562 
is a column II code to column I code 00560. 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 the anesthesia services coded as 00562 provided on August 25, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator.  
You asked the Plan to pre-approve a spinal cord stimulator. You say that the records provided support the need 
for the spinal cord stimulator. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. The Plan says that the enrollee has brachial plexus mass which is likely causing the arm 
pain. The Plan says that the enrollee has been offered neurosurgery to remove this mass and to treat the 
enrollee's arm pain and symptoms more definitively. The Plan says that the spinal cord stimulator is not a late 
or last resort. 
 
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 spinal cord stimulator. Our reviewer 
says that a spinal cord stimulator is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a brachial plexus mass that may be successfully managed with neurosurgical 
removal. More treatment options should be tried. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
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 rehabilitation is absolutely necessary and the 
enrollee is a good candidate for IRF. The Plan denied your request. The Plan says the denial of authorization 
for IRF service is correct. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital rehabilitation stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does have skilled therapy needs, but the documentation does not support a need for admission to an 
acute inpatient rehabilitation facility. The enrollee can receive further care 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have 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 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee may benefit from continued 
skilled therapy services. The documentation does not support that it is medically reasonable and necessary to 
provide skilled services on a daily basis on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds (12001) provided on 
July 25, 2021. 
 
You asked the Plan to pay for the simple repair of superficial wounds. You say that you would like this claim 
reprocessed for payment. The Plan denied your request. The Plan says this claim is included in the global 
surgery package for services previously rendered. 
 
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 12001 is simple repair of superficial wounds of scalp, 
neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less. 
 
We looked at the file and Medicare rules. Specifically, this claim is included within the global surgery for CPT 
24530 performed on June 13, 2021. This claim has a 90-day global surgery period. This claim was not billed 
with a modifier to indicate it as a distinct procedure from the surgery performed. Based on this information, we 
decided that Medicare rules for coverage of the simple repair of superficial wounds have not been met. Therefore, we decided that the Plan does not have to pay for the simple repair of superficial wounds (12001) 
provided on July 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexwalk system, hydraulic swing mechanism, knee-
shin flexion feature, and disarticulation knee extension assist feature for a lower limb prosthetic. 
 
You asked the Plan to pre-approve lower limb prosthetic components. You say that you are a K3 patient and 
meet requirements for these level 3 components. The Plan denied your request. The Plan says the denial of 
authorization for these components is correct, because the record does not support a need for K3 level 
components. 
 
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 lower limb prosthetic components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the physical therapy notes indicate that you demonstrate fatigue and 
exhaustion in therapy. You were using a single point cane and otherwise a wheelchair for mobility prior to the 
left above-knee amputation. These findings do not support a K3 level of ambulation; therefore, these 
components exceed your medical needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a flexwalk system, hydraulic swing mechanism, knee-shin flexion 
feature, and disarticulation knee extension assist feature for a lower limb prosthetic.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation 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 the records do not report a failed trial of at least four different medicines with adequate 
doses and duration. 
 
The Plan must follow Medicare rules. Medicare rules say that transcranial magnetic stimulation is covered 
when specific indications 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee had a PHQ 9 score of 18 as documented, which does not show this enrollee has a confirmed 
case of severe major depressive disorder, but rather moderate/severe major depressive disorder. The enrollee 
has been tried on several psychopharmacologic agents, but not from four different medication classes. 
 
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 transcranial magnetic stimulation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions - four 
or more teeth or tooth spaces, per quadrant (D7320). 
 
You asked the Plan to pre-approve alveoloplasty. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not covered under your benefits. 
 
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 
alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7320).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have 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 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee may benefit from skilled therapy 
services. The documentation does not support that it is medically reasonable and necessary to provide skilled 
therapy services on a daily basis on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor (CPT code K0553). 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The enrollee is not adjusting their insulin doses based on their blood 
glucose readings, so Medicare rules do not allow us to continue covering their supplies. Based on this 
information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor (CPT code K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Panzyga. 
 
You asked the Plan to pre-approve Panzyga. You say that the enrollee continues to have persistent symptoms. 
The Plan denied your request. The Plan says the use of Panzyga is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  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 Panzyga. Our physician reviewer found 
that in this case, the record indicates that the enrollee has diagnoses of autoimmune gastrointestinal dysmotility, 
noninfectious gastroenteritis, gastroparesis, and intestinal autonomic neuropathy. The FDA has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's specific clinical situation.  The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this 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 Panzyga have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Panzyga.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro motion G orthotic device (L8702) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the orthotic device. You say that this submission addresses the Plan's reason 
for denial and reviews the enrollee's medical necessity for the device. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 the MyoPro motion G orthotic device (L8702) to be provided by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is not able to return home 
without serious risk to his health. As such, SNF care is needed. The Plan denied your request. The Plan says no 
skilled needs are present. The request is custodial in nature. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation does not support 
that this patient requires skilled nursing services with the specialized skill, knowledge, and judgment of a 
skilled professional nurse to safely and effectively provide care only in a SNF. The patient does not have 
complex wound care or other SN need. The documentation does not support that this patient requires skilled 
nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely 
and effectively provide care only in a SNF. The patients functional level does not require the skills of a 
professional therapist only in a SNF. The patient does not require skilled nursing or skilled therapy on a daily 
basis only in a SNF. As a practical matter this patients medical needs do not require the necessary services on 
an inpatient basis in a SNF. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have a broken leg and cannot 
ambulate to the bathroom. The lightweight pads do not hold anything. These are necessary and should be 
covered The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 chiropractic therapy visits. 
 
You asked the Plan to pre-approve chiropractic care. You say that the requested visits are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested chiropractic visits 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 chiropractic care. Our reviewer says 
that the requested chiropractic care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has subluxations in the cervical, thoracic, and 
lumbar regions. The record provided indicates that the enrollee has been instructed on a home exercise program 
and has reached a point of maintenance therapy. The record provided does not establish an ongoing medical 
necessity for the requested services. Therefore, the reviewer found that the requested chiropractic services are 
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 chiropractic care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 4 chiropractic therapy visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of a heart monitor (33285). 
 
You asked the Plan to pre-approve the insertion of a heart monitor. You say that this procedure is needed to 
assist the enrollee's medical condition. The Plan denied your request. The Plan says this request is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an Implantable (or Insertable Loop) Recorder (ILR) is 
used when syncope is thought to be cardiac-related, but is too infrequent to be detected by either a HolterTM 
monitor or a traditional pre-symptom Memory Loop Recorder (MLR). 
 
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 insertion of a heart monitor. Our 
reviewer says that there is insufficient documentation to support the medical necessity for insertion of an ILR 
in this patients clinical management. Our physician reviewer found while the patient has a history of atrial 
fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. 
 
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 insertion of a heart monitor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an insertion of a heart monitor (33285).