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

 
We decided that the Plan has to pre-approve the continuation of inpatient psychiatric care from May 4, 2022, 
forward. 
 
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that this care 
continues to be medically necessary. The Plan denied your request. The Plan says that the criteria for coverage 
for inpatient psychiatric care have no longer been met. 
 
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 the continuation of inpatient psychiatric 
care. Our reviewer says that the requested inpatient psychiatric hospital care continues to be medically 
reasonable and necessary. Our physician reviewer found this 58-year-old female was admitted to the acute 
inpatient psychiatric hospitalization on April 28, 2022, with Major Depressive Disorder, Single Episode, 
Severe without Psychotic Features. Based upon review the records provided it was expected this enrollee 
would improve in a reasonable period of time for the dates in question as although she did not have suicidal or 
homicidal ideation, auditory or visual hallucinations. The patient was in the process of medication adjustment. 
It did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level 
of care rather than a lower level of care beyond the dates in question as the patient was in the process of 
medication adjustment. As a result, the requested care continues to be medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continuation of inpatient psychiatric care have been met. Therefore, we 
decided that the Plan has to pre-approve the continuation of inpatient psychiatric care from May 4, 2022, 
forward.  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department services provided August 31, 2020. 
 
You asked the Plan to pay for the emergency services. You say that you were told this was denied because you 
did not fill out the proper paperwork about a third-party insurer. You never received any paperwork and there 
was no third party. The Plan denied your request. The Plan says that the claim will be reconsidered if accident 
detail info is received from the enrollee. 
 
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. The Plan has not provided any supporting evidence that there is a third-party 
insurer. There is no evidence that a claim will be filed for the injury with a third party. The enrollee says that 
they did not fall while on the bus and that there is no third party. The Plan has not provided any information of 
a who the third-party insurer is and has not substantiated their reason to continue to deny. Therefore, we 
decided that the Plan has to pay for the emergency department services provided August 31, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral nutritional product. 
 
You asked the Plan to pre-approve an oral nutritional product. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve an oral nutritional product.
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 services. You say that this is medically necessary, as there is no mobility 
in the right leg. The Plan denied your request. The Plan says a basic group 3 power wheelchair with no power 
options is more appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that a power scooter is covered if the beneficiarys 
home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power 
operated vehicle, and if the enrollee is able to safely transfer to and from the power scooter.  
 
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 of note, based on the records provided, you do not possess adequate strength and stability to transfer to 
use the requested power scooter and the turning radius of the power scooter is too great for your apartment. 
 
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 a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. You say you are 
at a very high risk for falling and would greatly benefit from inpatient therapy. The Plan denied your request. 
The Plan says authorization because IRF care is not medically necessary, and your needs can be met at a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: 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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the rules for IRF care have not been met. 
 
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 patient was admitted for lumbar spine surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this 
patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29425-59-LT billed for date of service May 
6, 2021. 
 
You asked the Plan to pay for procedure code 29425-59-LT. You say that you have provided medical records 
to support payment. The Plan denied your request. The Plan says the medical records do not support that code 
29425-59 is separate and distinct from code 11042. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for procedure code 29425-59-LT Our reviewer 
says that modifier -59 is not supported in the medical record, so code 29425 is bundled into payment for code 
11042. Our physician reviewer found the procedure report documents debridement and application of 
application of short leg cast on the left extremity. In this case, casting would be inclusive to debridement 
procedure, when treating the same wound in the same anatomical location.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 29425-59-LT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 29425-59-LT billed for date of service May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia nerve block (01992) provided on June 15, 
2021. 
 
You asked the Plan to pay for the anesthesia nerve block (01992). You say that the attached addendum should 
be reviewed, and the claim reprocessed. The Plan denied your request. The Plan says the records do not support 
the number of units billed of CPT code (01992). 
 
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 01992 is anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different physician or other qualified health 
care professional); prone position. 
  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 anesthesia nerve block (01992). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the provider reported 46 units for anesthesia services. However, anesthesia report documents start time as 
11:57 and stop time of 12:13 which equals 16 minutes of anesthesia. In this case, the units billed cannot be 
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 anesthesia nerve block (01992) have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia nerve block (01992) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection procedure (27096). 
 
You asked the Plan to pre-approve an injection. You say that you have received injections in the past. The Plan 
denied your request. The Plan says the injection 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 an injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not show what percent pain relief that you had from earlier injections. 
The review has determined that the requested injection is not medically reasonable or 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 an injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection procedure (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (99204), and chiropractic treatment 
(90941). 
 
You asked the Plan to pre-approve the office visit and chiropractic treatment. You say that the service is 
medically necessary. The Plan denied your request. The Plan says there is no clinical or imaging evidence of 
spinal subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit and chiropractic treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the office visit (99204), and chiropractic treatment (90941).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar spine medial branch block (MBB). 
 
You asked the Plan to pre-approve a lumbar spine medial branch block (MBB). You say that a lumbar spine 
medial branch block (MBB) is medically necessary. The Plan denied your request. The Plan says that a lumbar 
spine medial branch block (MBB) does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of the 
Medicare LCD criteria. 
 
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 lumbar spine medial branch block 
(MBB). Our reviewer says that a lumbar spine medial branch block (MBB) is medically necessary. Our 
physician reviewer found that the request meets the criteria of the LCD. The procedure is medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar spine medial branch block (MBB) have been met. Therefore, we 
decided that the Plan has to pre-approve a lumbar spine medial branch block (MBB).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral splint. 
 
You asked the Plan to pre-approve the requested item. You say that you have excruciating pain. The Plan 
denied your request. The Plan says oral appliances for TMJ are not covered. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an oral splint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage 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 documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage 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 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 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the free muscle or myocutaneous flap (15756) provided on 
November 16, 2021. 
 
You asked the Plan to pay for the free muscle or myocutaneous flap (15756). The Plan denied your request. 
The Plan says procedure code 15756-62 is not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code free muscle or myocutaneous flap with microvascular 
anastomosis. 
 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the free muscle or myocutaneous flap (15756). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the operative report does not describe a free muscle or myocutaneous flap per NCCI Policy Manual 
to confirm this procedure has been performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the free muscle or myocutaneous flap (15756) have not been met. Therefore, we 
decided that the Plan does not have to pay for the free muscle or myocutaneous flap (15756) provided on 
November 16, 2021.