Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the proton beam treatment (PBT) (77014 and 77523). 
 
You asked the Plan to pre-approve the PBT. You say that the enrollee has one of the best indications for proton 
therapy over IMRT.  The Plan denied your request. The Plan says that the services are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 PBT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found proton therapy is not an accepted standard for routine radiation for rectal cancers; with 
exceptional circumstances (such as prior irradiation or unusual anatomy) it can be considered medically 
necessary. As proton therapy for recurrent rectal cancer in the setting of prior radiotherapy would be in 
accordance with accepted standards of care, our physician reviewer's decision is favorable.  
 
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 PBT have been met. Therefore, we decided that the Plan has to pre-approve 
the proton beam treatment (PBT) (77014 and 77523).  
 
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
LTACH services requested do not meet the requirements for approval.  
 
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 enrollee appears to be improving but is still somewhat unstable and requires 
additional acute care services that can safely be provided at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
the LTACH would not be clinically advantageous at this time and completion of treatment at the current 
facility is recommended.  
 
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: 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 this is medically necessary. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can 
safely receive the services they need in the current hospital setting. 
 
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 that the enrollee appears to be improving and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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: 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 the enrollee needs to be transferred to the 
LTACH to regain maximum/prior level of functioning and continue a multidisciplinary approach to care. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 enrollee appears to still be somewhat unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
the LTACH would not be clinically advantageous at this time and completion of treatment at the current 
facility is recommended.  
 
 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: 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 the enrollee is too sick to transition to 
lower level of care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met in the current inpatient hospital setting. 
 
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 that the enrollee appears to still be unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as the patient is not yet stable and as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended.  
 
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 you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 is functioning at a home care level and can improve without 
repetitive exercise. The enrollee does not have daily skilled nursing or therapy needs. 
 
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: Favorable

 
We decided that the Plan has to pre-approve the ganglion impar block (64999) performed on September 13, 
2022.  
 
You asked the Plan to pre-approve the service. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that the service was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is standard of care for cancer related pelvic pain. The procedure was totally 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve the ganglion impar block (64999) performed on September 13, 2022.   
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240).  
 
You asked the Plan to pre-approve a shower chair. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says this item is considered a comfort item 
and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable incontinence pads (Chuck Pads).  
 
You asked the Plan to pre-approve Chuck Pads. You say that you need these pads to protect against draining 
and weeping from your wounds.  The Plan denied your request. The Plan says these items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this 
case, neither the Plan nor Medicare offers coverage of these items. The Chuck Pads requested are considered 
disposable items that are primarily used as incontinence supplies. Therefore, we decided that the Plan does not 
have to pre-approve disposable incontinence pads (Chuck Pads).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records provided for review raise the 
possibility of AD. However, the records were silent on the enrollee potentially having FTD. The base 
requirement of the NCD for coverage are not have been 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an internal loop recorder (ILR) placement. 
 
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 an ILR is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation suggesting a 
history of unexplained syncope, cryptogenic stroke, or any other apparent indication for an ILR in this enrollee. 
The records do not support that the criteria for coverage are met and that the services are reasonable and 
medically necessary at this time. 
 
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 an internal loop recorder (ILR) placement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the electrostimulation (97139) provided on February 20, 
2023. 
 
You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied 
your request. The Plan says electrostimulation 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 pay for the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of any vitamin deficiency. There is no documentation of any edema. 
The physical exam does not detail the type and exact location of sensory loss. The therapies employed are not 
evidence based for this enrollee. The modalities were 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for  the electrostimulation (97139) provided on February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87500, 87801, 87798-59, 87493-59, 
87150-59, 87641-59) provided on February 2, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the laboratory results provided, appropriately supports a gastrointestinal panel CPT 
code 87607 rather than individual infectious agent codes that was billed on the date that service was rendered. 
The Plan states it was determined that this single panel code would have been more appropriate to billed for the 
performed testing of the 25 targets. 
 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 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 laboratory services. Our reviewer found based on the 
records provided and rules in the Medicare NCCI 2023 Coding Policy Manual, CPT code 87507 appears to be 
a more specific code for the services performed. The Medicare NCCI 2023 Coding Policy Manual - Chap 10 
CPT Codes 80000-89999 states: "Providers/suppliers shall report the HCPCS/CPT code that describes the 
procedure performed to the greatest specificity possible...The CPT Manual assigns CPT codes to organ- or 
disease-oriented panels consisting of groups of specified tests. If all tests of a CPT-defined panel are 
performed, the provider/supplier shall bill the panel code. The panel codes shall be used when the tests are 
ordered as that panel." Code 87507 describes a gastrointestinal panel 12-25 targets.  
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87500, 87801, 87798-59, 87493-59, 87150-59, 87641-59) 
provided on February 2, 2023.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, or home health services at home with supervision. 
 
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 was admitted for respiratory failure, chronic obstructive pulmonary 
disease (COPD), and atrial fibrillation. The enrollees medical problems are stable, and there are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with a radiation oncologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to continue to see the requested 
provider for radiation therapy after your surgery on August 7, 2023. You also say that contracted facilities that 
are within network are too far to travel back home after having therapy every day. The Plan denied your 
request. The Plan says you must use network providers for medical care and services. These services can be 
rendered by equally qualified community level providers. 
 
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 
an office visit (99204) with a radiation oncologist to be provided by an out-of-network (OON) provider.