Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30-day trial rental of pneumatic compressor, segmental 
home model with calibrated gradient pressure (CPT code E0652), segmental pneumatic appliance for use with 
pneumatic compressor, trunk (CPT code E0656), and segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT code E0667). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the submitted information fails to document that the enrollee completed and failed four 
(4) weeks of a conservative therapy trial with corresponding measurements. 
 
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 DME. Our physician reviewer 
found there is no documentation that the requirements listed in the LCD: Pneumatic Compression Devices 
(L33829) for Medicare coverage for the requested segmental pneumatic compression appliance have all been 
met in this case. Records do not document a four-week trial and failure of regular, daily, multiple-hour home 
usage of a standard pump (E0650 or E0651) as required by the LCD. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 30-day trial rental of pneumatic compressor, segmental home model with calibrated gradient 
pressure (CPT code E0652), segmental pneumatic appliance for use with pneumatic compressor, trunk (CPT 
code E0656), and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code 
E0667).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says that the requested continued SNF care 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 continued SNF care. Our reviewer says 
that the service is medically necessary. Our physician reviewer found you received oral medications, insulin 
and had stable vital signs. The most recent wound notes from 5/18/22 indicate you still have three wounds with 
one dressing being changed every other day and the other two with BID dressings with large or copious 
amounts of drainage. There are identifiable skilled nursing service needs. You do require skilled nursing or 
therapy services on a daily basis. You do meet severity of illness or intensity of service criteria for 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 continued 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 
continued 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from May 27, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 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 SNF 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 continuation of SNF care from May 27, 2022, forward.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine non-emergent transportation using a stretcher 
van (T2005). 
 
You asked the Plan to pre-approve non-emergent transportation using a stretcher van. You say that you are 
totally incapacitated, you cannot walk, and you cannot use a wheelchair. You also say you need to be 
transported to appointments by stretcher because no other means would work with your condition. The Plan 
denied your request. The Plan says your Plan does not cover transportation by stretcher or ambulance. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan does not cover transportation by stretcher or ambulance. The Plan covers a maximum of 60 one-
way trips per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine non-emergent transportation using a stretcher van (T2005).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical 
services to be rendered by the out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rectal prolapse surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a rectal prolapse surgery. You say that this provider does not have privileges 
at any of the Plan's hospitals. The Plan denied your request. The Plan says the member physician is in-network 
with the member's h health plan, but does not have privileges at any inpatient facilities or ambulatory surgery 
centers that are in-network for the member's health plan, and there are doctors in-network and have privileges 
at in-network facilities near your home that can take care of this problem. 
 
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 rectal prolapse surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extraction and alveoloplasty provided in a 
hospital for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are necessary. The Plan denied 
your request. The Plan says that these services 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. 
 
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 
dental extraction and alveoloplasty provided in a hospital for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says additional 
PT visits are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. Our reviewer found that 
you have had prior therapy and the documentation does not reveal that you require the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. Our physician reviewer also found 
that the requested services are not part of a maintenance program, and the specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your 
current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (NCS) and electromyography 
(EMG) testing provided on December 14, 2021. 
 
You asked the Plan to pay for the NCS/EMG services. You say that the State of New York indicates that this 
testing is within the scope of practice for a physical therapist. As such, no physician order is needed. The Plan 
denied your request. The Plan says this testing was not ordered by a treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. We find that there is no regulation which allows a physical therapist 
to provide this type of diagnostic testing without a physician order. The rules solely indicate that such testing 
may be performed without physician supervision when allowed by State law. Based on this information, we 
decided that Medicare rules for coverage of the NCS/EMG services have not been met.  
 Therefore, we decided that the Plan does not have to pay for the nerve conduction studies (NCS) and 
electromyography (EMG) testing provided on December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion, lumbar (CPT code (s): 20936, 22842, 
22612, 22614). 
 
You asked the Plan to pre-approve the surgical services. You say that the surgical services are necessary. The 
Plan denied your request. The Plan says the enrollee's records do not show other scheduled procedures that will 
cause their spine to become unstable. The Plan states they do not show that the enrollee's spine is badly curved, 
broken, or has bones slipping out of place. The Plan states the enrollee's records also do not show that their 
back has not healed after a prior surgery. 
 
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 surgical services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found dynamic flexion/extension films are not provided in order to potentially assess the 
amount of movement (instability) at the requested surgical level. Detailed documentation is not evident 
regarding potential impending/inevitable temporary intra-operative instability. Additionally, severe and/or 
progressive neurological abnormalities have not been documented. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the requested L4-5 and L5-S1 spinal fusion, lumbar (CPT codes 20936, 22842, 22612, 
22614), in this case, 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion, lumbar (CPT code (s): 20936, 22842, 22612, 22614).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan, abdomen and pelvis; with contrast material(s) (CPT code 
74177). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says that the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the CT scan. Our physician reviewer 
found based upon the clinical history the order for CT abdomen and pelvis was most reasonable for this 
enrollee's age and presentation and should be reimbursed. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT scan, abdomen and pelvis; with contrast material(s) (CPT code 74177).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that he requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is improving but still requires ongoing acute 
care services before being able to transition to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that she is not currently receiving but that would be available at the LTACH facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 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 SNF 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on June 24, 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 medication wastage is not documented in the medical records; therefore, J9299-JG,JW X 120 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 J9299 is "Injection, nivolumab, 1 mg." 
 
 
 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 the use of modifier "JG" will trigger a 
drug payment rate of ASP minus 22.5 percent. The JW modifier is a Healthcare Common Procedure Coding 
System (HCPCS) Level II modifier used on a Medicare Part B drug claim to report the amount of drug or 
biologic that is discarded and eligible for payment under the discarded drug policy. The case file does not 
contain documentation of medication wastage. Consequently, code J9299-JG,JW is not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on June 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 31, 
2021, to January 3, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were necessary. The Plan 
denied your request. The Plan says the inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation does not indicate signs of systemic infection or 
complexity of this case to warrant inpatient services. The reviewer found that there was no complication with 
the surgery and the enrollee was hemodynamically stable. Therefore, the reviewer found there was no 
expectation that the enrollee would require hospital care that would likely cross 2 midnights based on the 
provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 31, 2021, to January 3, 
2021.