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

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (E1230). 
 
You asked the Plan to pre-approve a POV. You say that the enrollee needs a scooter because they have cerebral 
palsy and full bilateral lower extremity weakness which is chronic. You also say that the enrollee cannot 
ambulate with a cane or walker, and cannot use a wheelchair because of their postural instability. The Plan 
denied your request. The Plan says the enrollee already has a group 2 power wheelchair that was provided in 
2022. The Plan also says there is no medically necessary reason that member needs a second POV. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a group 2 standard power wheelchair (K0823). A group 2 standard power 
wheelchair (K0823) serves the same purpose as a POV. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV) (E1230).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Synvisc, Durolane, and Gelsyn-3. The records do not show 
that the required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transportation services provided on October 6, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee needed to be transferred to a higher 
level of treatment. The Plan denied your request. The Plan says the services were not authorized.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 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 the billed services. Our physician reviewer 
found that there is no evidence that the enrollee required services that were not available at the sending facility.  
There is no evidence that closer facilities were not appropriate or unable to take the enrollee. Transfers for 
patient or family convenience or preference are not considered medically necessary. The air medical transport 
is not shown to have been medically necessary, reasonable or coverable. 
 
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 billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for air ambulance transportation services provided on October 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implanted cardiac defibrillator (ICD) (33249). 
 
You asked the Plan to pre-approve the implanted cardiac defibrillator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that an implanted cardiac defibrillator is covered when 
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 implanted cardiac defibrillator. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found implantation 
of an automatic defibrillator would not be considered medically necessary in the management of this patient. 
Records do not show the enrollee has any indication for a defibrillator based on current guidelines. 
 
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 implanted cardiac defibrillator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an implanted cardiac defibrillator (ICD) (33249).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 99292 billed for date of service 
December 1, 2022. 
 You asked the Plan to pay for procedure codes 99291 and 99292. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 99291 and 99292 is bundled into 
payment for code 92950. 
 
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 codes 
99291 and 99292 are column II codes to column I code 92950. 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 procedure codes 99291 and 99292 billed for 
date of service December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 16, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiotherapy (SBRT) (77370, 77373, 
77470). 
 
You asked the Plan to pre-approve SBRT. You say that the requested therapy is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinic notes do not demonstrate that this lesion is symptomatic. The documentation does not 
suggest that the enrollee is having pain from the T10 lesion, so the endpoints in the studies described above 
(with conflicting data on pain response) do not really apply for this enrollee. Based on a model policy, routine 
use of SBRT for palliation of spine metastases in the setting of more widespread disease is not in accordance 
with accepted standards of medical practice. The decision is unfavorable due to the case file not demonstrating 
necessity which would be needed when the treatment is not standard of care for routine practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiotherapy (SBRT) (77370, 77373, 77470).
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 services are medically necessary for the enrollee 
to regain their maximum function. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to an IRF. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 17, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
17, 2023.
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 you need medical care and don't think you will be 
safe at home. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that you have skin cancer and 
would like to have this treatment instead of surgery. The Plan denied your request. The Plan says the request 
does not meet the Medicare or health plan coverage criteria. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually image-guided radiation treatment (IGRT) is used when critical 
structures are abutting or in close proximity to the target that is being treated to high doses. This situation does 
not apply to you for which the target lesion can be seen on the skin to assist in daily set up. When treating skin 
cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is Food and Drug 
Administration (FDA) approved for use with ultrasound though that in and of itself does not mean that daily 
imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill 
for daily simple simulations and/or IGRT for a technology for which need has not been established by 
published data or supported by consensus guidelines (many of which recommend against treatment with these 
devices in general) is not necessary. The decision is unfavorable as billing for daily IGRT which would not be 
furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization.  The Plan denied your request. The Plan says the requested IRF services do not meet the 
requirements for approval. 
 
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 that the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided December 9, 2022, to January 4, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like to appeal the 
decision not to pay for certain therapies instrumental in reducing the risk of post-operative complications. The 
Plan denied your request. The Plan says a PCD coded as E0675 is not eligible for reimbursement and denied as 
not reasonable and necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
December 9, 2022, to January 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally-invasive percutaneous left sacroiliac (SI) 
joint fusion with LinQ SI joint stabilization system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has degenerative back 
conditions with stenosis. SI joint fusion for degenerative back pain is considered experimental in nature. There 
is no documented SI joint instability. The services are therefore not reasonable or medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve minimally-invasive percutaneous left sacroiliac (SI) joint fusion with LinQ SI joint 
stabilization system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service August 24, 
2022.  
 
You asked the Plan to pay for procedure code G0480. The Plan denied your request. The Plan says payment for 
code G0480 is bundled into payment for code G0482. 
 
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 G0480 
is a column II code to column I code G0482 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code G0480 billed for date of service August 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you have been waiting for this service for 
over a month and the physician agreed that more physical therapy was medically necessary.  The Plan denied 
your request. The Plan says that additional physical therapy is not medically 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 the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.