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

 
We decided that the Plan does not have to pre-approve an enclosed frame walker. 
 
You asked the Plan to pre-approve an enclosed frame walker. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that medical necessity for a walker with an enclosed 
frame (E0144) has not been established. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested item is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of an enclosed frame walker 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an enclosed frame walker.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a penile prosthesis implant.  
 
You asked the Plan to pre-approve a penile prosthesis implant. You say that the patient suffers from erectile 
dysfunction and he suffers from depression due to this issue. The Plan denied your request. The Plan says the 
requested penile prosthesis implant 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 a penile prosthesis implant. Our 
reviewer says that the requested penile prosthesis implant is not considered medically reasonable and necessary 
in this case. Our physician reviewer found that in this case, the record indicates that the enrollee has erectile 
dysfunction following cystectomy. The record provided is insufficient to establish the medical necessity of the 
requested service for the enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied.   
 
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 penile prosthesis implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a penile prosthesis implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service December 24, 2022. 
 
You asked the Plan to pay for code 99223. You say that all of the components of code 99223 were documented 
in the medical record. The Plan denied your request. The Plan says code 99223 is not supported by the medical 
record. The medical records do not support medical decision making of high complexity. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history, 
a comprehensive exam, and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not supported by the medical record. Our reviewer found the enrollee is a 70-year-old woman with a history of 
hypertension, pulmonary embolism, and recent neurosurgery on the spine who presented with the inability to 
walk after arriving home from rehab. In this case, the documentation supports a comprehensive exam, but not a 
comprehensive history or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service December 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a power wheelchair (codes K0739, E2395, 
E2389, E2374, E2394, E2390, E2366, K0040, K0043, E1028, E0995, K0019, and K0108). 
 
You asked the Plan to pre-approve repairs to a power wheelchair. You say that most of your wheelchair is 
either broken or working incorrectly. You also say that you can tell someone was messing with it, and it does 
not look anything like the chair in the book. The Plan denied your request. The Plan says the requested services 
are not a covered benefit.  
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 repairs to a power wheelchair. Our 
physician reviewer found the documentation available for review does not indicate that you have an appropriate 
diagnosis for a group 3 power wheelchair or that you are unable to accomplish mobility-related self-care tasks 
in the home with an alternative assistive device. Additionally, there is no clear documentation regarding how 
old the power wheelchair is. Our reviewer found that the documentation available for review does not support 
the medical necessity of the power wheelchair, therefore, the repair of the power wheelchair is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Specifically, the file does not show that you 
have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. 
Based on this information, we decided that Medicare rules for coverage of repairs to a power wheelchair have 
not been met. Therefore, we decided that the Plan does not have to pre-approve repairs to a power wheelchair 
(codes K0739, E2395, E2389, E2374, E2394, E2390, E2366, K0040, K0043, E1028, E0995, K0019, and 
K0108).
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. The Plan 
denied your request. The Plan says the services needed can be provided in an alternate setting.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, E1007, 
E1012, E1028, E2361 x2, E2608, and E2620). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that the enrollee's primary diagnosis of stage 3 Parkinsons disease, 
with resultant tremors, limits their ability to functionally ambulate effectively and safely. The Plan denied your 
request. The Plan says the enrollee does not have medical need for multiple power options available with 
K0861 group 3 power wheelchair. The Plan also says an expandable controller, harness, and electronics are not 
medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say if the PWC base is not covered, then related accessories will be denied. 
 
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 group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found the enrollee has a neurologic disorder with 
functional deficits. The documentation does not indicate that the enrollee has any pressure injuries or requires 
intermittent catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Our 
reviewer found that although the enrollees condition may meet criteria for a PWC, the criteria for this 
specifically requested PWC with multiple power options including power tilt and recline are 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 a group 3 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E2311, E2313, E2377, E0955, E1007, E1012, E1028, E2361 x2, E2608, and E2620).
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 you want to go to inpatient rehabilitation to regain 
your independence and be safe to return home. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare guidelines. The Plan says that the services needed may be provided 
safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care (99222) 
provided on March 7, 2023. 
 
You asked the Plan to pay for initial hospital inpatient or observation care. You say that Medicare does pay for 
CPT code 99222 in an emergency setting. you have attached clinical notes supporting medical necessity. The 
Plan denied your request. The Plan says the evaluation and management service were billed with an incorrect 
place of service (POS). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Specifically, the record shows that this claim was billed with POS 
code 23 indicating that the services were rendered in a hospital emergency room. The documentation submitted 
indicates that the enrollee was in inpatient/observation care. POS 23 is not appropriate in this case. Based on 
this information, we decided that Medicare rules for coverage of initial hospital inpatient or observation care 
have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital inpatient or 
observation care (99222) provided on March 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigational procedure for 
musculoskeletal procedures (20982) for a total knee arthroplasty (TKA). 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that you were not informed 
you needed to call within three days to schedule a peer to peer. The Plan denied your request. The Plan says it 
has not been shows that this procedure is better than other types of standard knee surgeries. The Plan also says 
it has not been shown to decrease the possible need for additional surgery or improve health outcomes. 
 
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 computer-assisted surgical navigation. 
Our reviewer says that the requested computer-assisted surgical navigation is not considered medically 
reasonable and necessary in this case. Our physician reviewer found no large volume, long-term/high-quality clinical studies confirm the clinical benefits of computer-assisted surgery over standard surgical approaches in 
total knee arthroplasty. There is no compelling rationale presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested computer-assisted 
surgical navigational procedure for a total knee arthroplasty 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 computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigational procedure for 
musculoskeletal procedures (20982) for a total knee arthroplasty (TKA).
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 enrollee is ready for acute rehabilitation level of 
care with the ability to tolerate a high level of activity and a reasonable plan to discharge home. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements. The Plan says that 
the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 you been experiencing Knee pain and need 
rehabilitation. The Plan denied your request. The Plan says documentation does not support that you require an 
intensive and coordinated interdisciplinary approach to providing rehabilitation. The Plan says that the services 
needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the SNF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for SNF 
admission. 
 
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 that the enrollee does not have documented skilled nursing or skilled therapy needs. 
The enrollee's care needs can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral (64635, 64636). 
 
You asked the Plan to pre-approve the radiofrequency ablation (RFA). You say that you have been having 
injections and ablations done to your back. You say that now they are being denied. You say that these 
procedures help to keep you from needing to take so many pain pills. You also say that you need these to be 
approved so you can feel better. The Plan denied your request. The Plan says none of the records provided 
document an examination of your spine. 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the lateral sacral branches has a very variable efficacy and for that reason, it 
is considered experimental. Therefore, the reviewer found that this request is not 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), 
with imaging guidance (fluoroscopy or CT); lumbar or sacral (64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99205, 99214) with an oncologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you are requesting reconsideration for the denied 
office visits. The Plan denied your request. The Plan says the enrollee must receive services from an in-network 
provider. There are in-network providers within a reasonable distance from the enrollee's location that can 
provide the service. 
 
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 
office visits (99205, 99214) with an oncologist to be provided by an out-of-network (OON) provider.