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

 
We decided that the Plan does not have to pre-approve brachytherapy.  
 
You asked the Plan to pre-approve brachytherapy. You say that radiation therapy is a common treatment 
modality for the treatment of non-melanomatous skin cancers, especially for elderly patients with lesions in 
cosmetically sensitive areas. You say radiation treatment for skin cancer can be delivered with traditional 
electron beam therapy via a linear accelerator or with high-dose rate (HOR) brachytherapy, which includes 
electronic brachytherapy. The Plan denied your request. The Plan says brachytherapy 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 brachytherapy. Our reviewer says that 
the requested brachytherapy is not considered medically reasonable and necessary. Our physician reviewer found that the National Comprehensive Cancer Network (NCCN) Guidelines state: "There are insufficient 
long-term efficacy and safety data to support the routine use of electronic surface brachytherapy." In addition, 
the provided records do not document that the lesion is not amenable to surgical removal, which is the primary 
treatment for this condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of brachytherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brachytherapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional hours of neuropsychological testing. 
 
You asked the Plan to pre-approve 7 additional hours of testing. You say that this is necessary to be able to 
provide appropriate care to the enrollee. The Plan denied your request. The Plan says additional hours of testing 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that typically, psychological testing will require from four 
(4) to six (6) hours to perform, including administration, scoring and interpretation. Supporting documentation 
in the medical record must be present to justify greater than 8 hours per patient per evaluation. If the testing is 
done over several days, the testing time should be combined and reported all on the last date of service. If the 
testing time exceeds eight (8) hours, medical necessity for extended time should be documented. 
 
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 7 additional hours of testing. Our reviewer says that the requested 7 additional hours of neuropsychological testing is not medically necessary. 
Our physician reviewer found the provided records do not document a complexity of the enrollee's condition 
such that more than 8 hours of testing would be medically necessary for the evaluation. Therefore, the request 
for 7 additional hours of testing 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 7 additional hours of testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 7 additional hours of neuropsychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt and recline system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that power tilt and recline 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 power tilt and recline is not medically necessary. Our physician reviewer found the enrollee is functionally 
non-ambulatory and cannot use a cane or walker for mobility. He does not have a history of skin breakdown or 
impaired sensation and does not require power tilt for pressure relief. He primarily has lower extremity 
weakness, fatigue, and lower extremity edema. Therefore, the PWC and power foot platform are medically 
necessary and the power tilt and recline feature does not meet the criteria for coverage and is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power tilt and recline system.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the surgical procedure under B-Safer trial protocol provided on 
February 11, 2023. 
 
You asked the Plan to pay for the surgical procedure. You say that you are requesting reimbursement for the 
services that have been provided. The Plan denied your request. The Plan says that it is not clear if this is a 
Medicare approved trial. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records do not support the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of the surgical procedure under B-Safer trial 
protocol. Specifically, no information was provided supporting that patients need to be in a Medicare approved 
trial for this procedure. It is the burden of the Plan to substantiate their denial with evidence. In this case, the 
denial has not been substantiated. Therefore, we decided that the Plan has to pay for the surgical procedure 
under B-Safer trial protocol provided on February 11, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this procedure could help determine the cause of 
the enrollee's neurocognitive disorder. 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 that the record provided does not establish 
that the enrollee meets the diagnostic criteria of both AD and FTD. The elements of the coverage criteria are 
not satisfied. The requested service cannot be covered 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0201 billed for date of service May 8, 2023, 
to May 12, 2023. 
 You asked the Plan to pay for procedure code S0201. You say that S0201 should be paid as billed because the 
enrollee has dual coverage and other claims have processed correctly in the past. The Plan denied your request. 
The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S0201 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0201 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0201 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0201 billed for date of service May 8, 2023, to May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95957 rendered on May 8, 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 this does not meet the coding standards. 
 
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 95957 is "Digital analysis of electroencephalogram 
(EEG) (eg, for epileptic spike analysis)." 
 
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 records support a different 
code than what was billed. Procedure code 95957 cannot be verified and is not supported by the documentation. 
 
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 procedure code 95957 rendered on May 8, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 hours of neuropsychological testing. 
 
You asked the Plan to pre-approve the testing. You say that the enrollee is experiencing global impairment in 
social and adaptive functioning due to symptoms. You also say that the enrollee wants to use this testing as a 
means to gain diagnostic clarity and seek treatment for these symptoms. The Plan denied your request. The 
Plan says this testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that testing conducted when no mental 
illness/disability is suspected would be considered screening and would not be covered by Medicare. Non-
specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable 
indication for testing. 
 
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 testing. Our reviewer says that the 
requested 12 hours of neuropsychological testing are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that the 12 hours of neuropsychological testing 
at issue in this case meet all Medicare criteria for medically reasonable and necessary for the enrollee. The 
objective assessment in the provided records reports the enrollee's thought processes, memory, attention and 
concentration and judgement and insight are all within normal limits. The reviewer found that the provided 
records are inadequate to justify the necessity of 12 hours of neuropsychological testing that cannot be completed independently or as part of a routine clinical examination. Therefore, the reviewer found that the 
requested 12 hours of testing 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 12 hours of neuropsychological testing.
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 IRF is needed to be able to live independently. The 
Plan denied your request. The Plan says the denial of IRF care is correct.  
 
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 this 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot inserts you purchased on June 6, 2023. 
 
You asked the Plan to pay for the foot inserts. You say that you would like to appeal this denial. The Plan 
denied your request. The Plan says the provider from whom you purchased these inserts is not a Medicare-
certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for foot inserts you purchased on June 6, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper arm orthosis (L8702). 
 
You asked the Plan to pre-approve the powered upper arm orthosis. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 powered upper arm orthosis. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested orthosis is not the standard of care for this patient's condition or in 
widespread use for this patient's condition based on scientific evidence. 
 
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 powered upper arm orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a powered upper arm orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G orthotic brace. You say that the MyoPro is supported 
as an appropriate intervention and is reasonably and medically necessary as recognized by medical 
communities and key opinion leaders in rehabilitation. The Plan denied your request. The Plan says the 
MyoPro device is considered experimental, investigational, or unproven. 
 
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 MyoPro Motion G orthotic brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific 
evidence, professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for this patient's condition or in widespread use for this patient's condition based on scientific 
evidence. Our reviewer found that there is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this patient. Our physician reviewer also found that there is insufficient 
evidence in the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro Motion G orthotic brace have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G orthotic brace (L8702).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on July 28, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that services rendered by non-participating providers require prior 
authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided the Plan rule or a Medicare rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for psychotherapy provided on  
July 28, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 to request reconsideration of the 
denied IRF services and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the inpatient rehabilitation facility (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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual, the medical record 
overall significantly complies with the various documentation requirements for IRF admission (e.g., as best 
summarized by the evaluations from November 1, 2023).  This enrollees condition is in fact sufficiently 
complex and fragile, and there is every reason to expect that they will participate in and benefit from IRF level 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.