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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, seat elevator, legrests), and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that you 
want to appeal this denial. The Plan denied your request. The Plan says the enrollee does not have a medical 
need for the requested power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria are 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided records do not show that the 
enrollee has a high risk for skin breakdown, uses a catheter intermittently, has spasticity or requires an 
alternative means of managing power drive. The record is insufficient in detailing high risk for skin 
breakdown. The enrollee does not rely on intermittent catheterization. Therefore, the reviewer found that the 
requested Group 3 power wheelchair 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 Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, seat elevator, legrests), and accessories.
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 admission to IRF is a medical necessity and potential 
benefits of this level of care. The Plan denied your request. The Plan says based on Medicare guidelines, the 
IRF services you are requesting 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 the enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services and regular physician evaluation.  The enrollees care needs can be met 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity joint (73718, 73719, 
73721), an MRI of the leg (73720) and quantitative magnetic resonance for analysis of tissue composition 
(0649T). 
 
You asked the Plan to pre-approve an MRI of the lower extremity joint (73718,73719 73721) an MRI scan of 
the leg (73720) and Quantitative magnetic resonance for analysis of tissue composition (0649T) . You say that 
the enrollee's knee gives out on them daily which causes other injures to the body when they fall. You say that 
the MRI was ordered to obtain all relevant clinical data of the anatomical structures of the knee, as well as the 
overall alignment of the entire limb. The Plan denied your request. The Plan says that an MRI of the lower 
extremity joint, an MRI scan of the leg joint and quantitative magnetic resonance for analysis of tissue 
composition is not medically necessary.  
 The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lower extremity joint 
(73718,73719 73721) an MRI scan of the leg (73720) and Quantitative magnetic resonance for analysis of 
tissue composition (0649T). Our reviewer says that an MRI of the lower extremity joint (73718,73719 73721) 
an MRI scan of the leg (73720) and Quantitative magnetic resonance for analysis of tissue composition 
(0649T) are not medically necessary. Our physician reviewer found that the enrollee is presented with right 
knee pain that gives them daily discomfort. However, there are no large volume, long-term or high-quality 
clinical studies to confirm the clinical benefits of computer assisted surgery over standard surgical approaches 
in total knee arthroplasty. The procedure itself is not necessarily supported. Also, the provided examination did 
not corroborate any significant bony deformity of the right knee and shaft. Therefore, the requested magnetic 
MRI of the knee and leg with analysis of tissue composition 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 MRI of the lower extremity joint (73718,73719 73721) an MRI scan of the 
leg (73720) and Quantitative magnetic resonance for analysis of tissue composition (0649T) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an MRI of the lower extremity joint (73718, 
73719, 73721), an MRI of the leg (73720) and quantitative magnetic resonance for analysis of tissue 
composition (0649T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pluvicto. 
 
You asked the Plan to pre-approve Pluvicto. You say that the enrollee is not a candidate for chemotherapy as it 
is contraindicated. The Plan denied your request. The Plan says the requested drug is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pluvicto. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the requested use of Pluvicto is 
not FDA-approved for the enrollees diagnosis without a prior taxane. The use of the requested drug is no 
supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pluvicto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pluvicto.
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 would benefit from IRF to address his 
functional impairments including transfers, ambulation, activities of daily living skills and syncopal episodes. 
The Plan denied your request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility 
services requested 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 the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on June 20, 2023, to June 22, 2023, 
billed with code G0423-59 (3 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that payment for this code is bundled into payment 
of another code. 
 
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 G0423 
is a column II code to column I code G0422; however, G0423 was billed with a modifier. 
 
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 practitioner services provided. Our reviewer says that 
documentation does support the billed code. Our reviewer found that the record supports that G0423 is a 
separate and distinct service. The record states the services were given at different times in different sessions. 
As such, the bypass modifier use is supported. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on June 20, 2023, to June 22, 2023, billed with code G0423-
59 (3 units).  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that if you do not receive these services; then you will 
not heal. The Plan denied your request. The Plan says these services are not medically necessary.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an OON provider on June 
27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided by an OON 
provider on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you have treated the enrollee and 
recommend that the enrollee be discharged home with a trilogy ventilator. The enrollee has been seen multiple 
times since 2022, and it has been established that BIPAP is not sufficient to support the enrollee's needs. The 
Plan denied your request. The Plan says you do not meet criteria for approval of a ventilator. 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, severe 
obesity, and congestive heart failure. The enrollee was recently hospitalized with an exacerbation of COPD and 
heart failure and improved with diuresis and BiPAP. The enrollee was also previously hospitalized with 
respiratory failure in January of this year. Arterial blood gases have been consistent with acute on chronic 
hypercarbic respiratory failure. This enrollee may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) during sleep as an outpatient. The records do not show this has been tried and failed as an 
outpatient.  Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 2, 2023, to June 6, 
2023. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that inpatient care was medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee's needs could have 
been met at a lower level of care. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was given intravenous antibiotics for a urinary infection. She was 
discharged on June 6, 2023, when considered medically stable. The review has determined that the record 
showed that at the time of inpatient admission it was reasonable for the admitting physician to expect that the 
enrollee's necessary hospital care would span two midnights with supporting documentation of the enrollees 
history, comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from June 2, 2023, to June 6, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neurophysiology monitoring coded as 
G0453, and the neuromuscular junction testing coded as 95937 performed on May 11, 2023. 
 You asked the Plan to pay for G0453 and 95937. You say that G0453 and 95937 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says G0453 is denied 
because payment for this code is bundled into payment for code 95955. 95937 is denied because it is not 
supported in the documentation. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
The CPT Code Manual definition of code G0453 is continuous intraoperative neurophysiology monitoring, 
from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) 
each 15 minutes (list in addition to primary procedure). In this case, we have confirmed that G0453 is a column 
II code to column I code 95955. However, G0453 was billed with a modifier. 
 
 The CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, 
paired stimuli), each nerve, any 1 method. 
 
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 G0453 and 95937. Our reviewer says that G0453 and 95937 
are not supported in the documentation. Our reviewer found that despite G0453 being billed with modifier -59, 
records do not support it is a distinct and separate procedure. The electroencephalogram (EEG) monitoring 
during surgery reported with code 95955 is a more extensive procedure and includes the services reported with 
G0453. Regarding 95937, the record states this code was reported for train of four testing, which is not a 
separately reportable procedure, therefore this code is unsupported. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G0453 and 95937 have not been met. Therefore, we decided that the Plan does 
not have to pay for the intraoperative neurophysiology monitoring coded as G0453, and the neuromuscular 
junction testing coded as 95937 performed on May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair with multiple power options and accessories. 
You say that this is the appropriate equipment for the enrollee's needs. The Plan denied your request. The Plan 
says the enrollee does not have medical need for the multiple power options included with this wheelchair. 
 
The Plan follows Medicare rules. Medicare rules state that power wheelchairs may be covered if certain criteria 
are met. If the base power wheelchair is denied, all related accessories will also 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 Group 3 power wheelchair with 
multiple power options and accessories. Our reviewer says that the enrollee does not meet criteria for this 
wheelchair. Our physician reviewer found the records do not support that the enrollee is high risk for skin 
breakdown and is unable to perform a functional weight shift, has a history of pressure ulcer, or has had a skin 
flap surgery. 
 
As the enrollee does not meet criteria for the base power wheelchair, all related accessories in this request are 
automatically denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 3 power wheelchair with multiple power options and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair 
with multiple power options and accessories.