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

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the IRF stay 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Neuravive treatment (CPT code 0398T). 
 
You asked the Plan to pre-approve the Neuravive treatment. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the Medicare rules have not been 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 Neuravive treatment. Our physician 
reviewer found the LCD criteria 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 the Neuravive treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Neuravive treatment (CPT code 0398T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and multiple power 
options/features/accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical need for multiple power options. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the ddocumentation does not indicate that the enrollee has any pressure injuries or requires 
intermittent catheterization of the bladder that would necessitate power tilt or recline. The requested electrical 
accessories are not medically necessary as the member does have use of the upper extremity and can operate 
and control the power options using the switches that are included in the basic wheelchair. The medical 
necessity for a group 3 wheelchair with multiple power options is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and multiple power options/features/accessories.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided on March 
23, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says the copayment that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for a Medicare-covered radiological diagnostic services.  
 
 
 
 
 
 
 You have been asked to pay the allowed amount of $108.25, which is less than the $110 copayment for a 
diagnostic ultrasound. A diagnostic ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic 
ultrasound provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99251 billed for date of service August 23, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the procedure has been coded per guidelines. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99251 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99251 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99251 billed for date of service August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (83789) provided on February 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says modifier -59 is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the lab services (83789) provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 35302) provided to the 
enrollee on December 8, 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 the records do not support the services billed. 
 
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 35302 is "Thromboendarterectomy, including patch graft, 
if performed; superficial femoral artery." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the ddocumentation does not 
support coverage of the code in question. Endarterectomy that extends from the common femoral into the deep 
and superficial femoral arteries is only billable as a single code for that groin.  
 It is not appropriate to code for endarterectomy of plaque that extended into the superficial femoral at the time 
of common femoral endarterectomy. There is no documentation that the superficial femoral endarterectomy 
was performed as a distinct separate entity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 35302) provided to the enrollee on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 15, 2022. 
 
You asked the Plan to pay for the services provided. You say that the testing was necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says there is no 
evidence the referring provider was treating the enrollee. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   
 
We looked at the file and the rules. The documentation does not show that the testing at issue was ordered by 
the enrollees treating physician for a specific medical problem or treatment strategy. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that BiPAP flow capability is extremely limited. The 
Plan denied your request. The Plan says settings that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that the enrollee has severe COPD and mild chronic carbon dioxide retention. She may benefit from 
BiPAP during sleep as an outpatient. However, Medicare does not cover a home ventilator when used as 
BiPAP. Therefore, the request 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (86334) provided on November 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 86334 is "Immunofixation electrophoresis; serum". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 86334 is 
not supported by the records provided. Our reviewer found that the documentation must include "The lab 
analyst performs the technical steps to test the patients serum using immunofixation electrophoresis which 
involves a method such as precipitation. The test includes the separation of serum proteins according to their 
size, shape, and electric charge with the help of an electric field on a gel. The lab analyst adds antigen to these proteins. Precipitation lines appear as narrow bands on the gel, which indicates the presence of an antibody. 
Results are reported either positive or negative to indicate the presence or absence of the antibody." The 
provided documentation does not support this was 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (86334) provided on November 22, 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 the services you need can be provided safely in other settings. 
 
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. Your medical status does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional multiple therapies, including 
physical and occupational therapy, the documentation does not reveal that you require this therapy or can 
tolerate this IRF intensive therapy given your history of fatigue and pain in therapy. 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 a microprocessor knee and advanced foot system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request does not meet Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical 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 the requested services. Our physician 
reviewer found that the documentation from the treating provider does not support that this enrollee is a K3 
ambulator and has the ability to traverse most environmental barriers and may have vocational, therapeutic, or 
exercise activity that demands prosthetic utilization beyond simple locomotion. The documentation from the 
treating practitioner does not support that this patient requires a microprocessor knee over a standard 
mechanical knee. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee and advanced foot system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (64483, 64484). 
 
You asked the Plan to pre-approve repeat injections. You say that you have completed all of the requirements. 
The Plan denied your request. The Plan says the requested injections are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that ESIs are medically necessary when the requirements 
have been 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 repeat injections. Our reviewer says 
that the requested epidural steroid injections are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate the enrollee has received physical therapy. The documentation does 
not include any advanced imaging either. Therefore, the request epidural steroid injections are considered 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 repeat injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve repeat epidural steroid injections (64483, 64484).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of humerus (73060) provided on April 27, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the referring physician and provider are out-of-network, and the services were not 
approved in advance. 
  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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the x-ray exam of humerus (73060) provided on 
April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that significant clinical and diagnostic 
patient specific data in support of medical necessity is included in the documents provided. The Plan denied 
your request. The Plan says medical studies haven't proven this service is helpful for the treatment of the 
enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that an Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are multiple plausible pathologic sources of significant pain generation in the 
enrollee's case. The non-radiating midline back pain, the noted pain-aggravating factors, along with the 
diminished and painful spinal motion were/are all non-specific to any pathologic entities. The documentation is 
lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as 
being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. Overall, there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the request for Intracept 
intraosseous basivertebral nerve ablation at L4 and L5 levels 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs are custodial and custodial care is not covered. 
 
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. There 
are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do 
not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility setting. Our physician reviewer found that 
your condition does not meet Medicare criteria for SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.