Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation and psychotherapy 
services provided from March 7, 2023, to March 28, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation and psychotherapy services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says this provider is a Licensed 
Marriage and Family Therapist (LMFT), which is not recognized as an independent provider type by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation and 
psychotherapy services provided from March 7, 2023, to March 28, 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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is 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 the enrollee's nursing, medical, and rehabilitation needs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22513). 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was no trial of bracing for fracture treatment. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty procedure (22513).
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 appealing the denial of the requested 
inpatient rehabilitation facility (IRF) services. The Plan denied your request. The Plan says the IRF 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 these services are medically necessary. 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 based on the documentation provided, the enrollee does not require the intensity of 
services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation.  The enrollee is functioning at a level commiserate 
with her weight-bearing restrictions.  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99212-
25) rendered on March 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records do not indicate appropriate use of modifier 25 for CPT 99212. 
 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 99212 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and straightforward medical decision making. When using time for code selection, 10-19 minutes 
of total time is spent on the date of the encounter." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation submitted does 
not support procedure code and modifier billed. The evaluation and management service documented is 
directly related to the procedure performed. The records do not support a separately identifiable evaluation and 
management service. This service was for bilateral knee pain, and treatment was given for the pain. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99212-25) rendered on March 9, 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the Medicare 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 documentation does not support that the enrollee's care is complex enough to 
warrant an acute hospital inpatient stay. Although it appears the enrollee would be able to participate, the 
enrollee does not require an intensive rehabilitation therapy program. Therefore, the enrollee does not need an 
IRF level of rehabilitation.  
 
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 power wheelchair and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2605, E2620, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found you 
do not have a qualifying diagnosis of myopathy, neurologic disease, or congenital spine deformity. 
 
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 and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2605, E2620, K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (PBT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary, and a standard of care. 
The Plan denied your request. The Plan says there is no compelling data to suggest that proton beam therapy is 
superior to or more beneficial than intensity modulated radiation therapy/image-guided radiation therapy 
(IMRT/IGRT). 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the IMRT/ volumetric modulated arc therapy (VMAT) plan in this case would be safe and effective. 
The enrollee is not in a clinical trial or registry. There is no level 1 evidence that proton beam therapy provides a superior outcome compared to IMRT/VMAT, especially considering the available data for PBT in the post-
operative setting. The plan comparison (Proton vs. Photon)/DVH comparison data was reviewed in detail. 
While PBT can provide some dosimetry advantage in this case, the IMRT/VMAT plan meets the constraints 
recommended by Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC). 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy (PBT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remaining 5 extractions provided on May 25, 2023, to 
June 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for an annual dental allowance amount was exhausted on date of service June 1, 2023. Therefore, we decided that the Plan does not have to pay for the remaining 5 extractions provided on May 25, 
2023, to June 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pegasys injection, a self-administered drug. 
 
You asked the Plan to pre-approve a self-administered drug. You say that the requested drug is medically 
necessary for the enrollee's continuation of care. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pegasys injection, a self-
administered drug.  
 
Benefits for a self-administered drug may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-area surgeon. 
 
You asked the Plan to pre-approve these services. You say that this is the only provider that can perform the 
surgery you need. The Plan denied your request. The Plan says the services are available from in-area, in-
network providers. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that you are requesting services from an out-of-area 
surgeon for possible surgery. The services are not for an unforeseen illness or injury. The Plan confirmed that there are in-area, in-network surgeons available to provide the procedure. 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 a referral to an out-of-area surgeon.
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says the requested SNF services requested do not meet the requirements for approval.  
 
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 has improved bed mobility but remains at moderate assist for 
transfers and is dependent for ambulation. The enrollee is responding to therapy. There are no clinical criteria 
for transferring the enrollee to a SNF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that TTE are 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 a TTE. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found clinical guidelines do not support repeating 
a TTE with no intervening change in clinical status or physical findings. In summary, there is no supportive 
evidence for the medical necessity of repeat TTE in this enrollee's clinical management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 31500, 92950, 92960, 99291 rendered on January 15, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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 
the denied codes is: 
 
CPT 31500: 
 
Intubation, endotracheal, emergency procedure 
 
CPT 92950: 
 
Cardiopulmonary resuscitation (eg, in cardiac arrest) 
 
CPT 92960: 
 
Cardioversion, elective, electrical conversion of arrhythmia; external 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that in terms of CPT 31500, the provider 
clearly documents the endotracheal. The enrollee tolerated it well, with no immediate complications. 
 
In terms of CPT 92950, the provider clearly documents "cardiopulmonary resuscitation (CPR) in progress." 
Therefore, this code is supported in the records. 
 
In terms of CPT 92960, the provider clearly documents electrical cardioversion with electrode placement, 
mode, shock, and decision to terminate. Therefore, this code is supported in the records. 
 
Finally, in terms of CPT 99291, the provider clearly documents the critical care services that were provided. 
The services included intubation, peripheral IV, electrical cardioversion, CPR, and labs. The records document 
that 35 minutes of critical care services were performed. Therefore, this code is supported in the records.  
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 31500, 92950, 92960, 99291 rendered on January 15, 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.