Persius/hicric huggingface dataset:
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 the enrollee's ongoing skilled therapy and nursing needs can be provided at 
a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does 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 the enrollee 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical spinal cord stimulator. 
 
You asked the Plan to pay for a cervical spinal cord stimulator. You say that the cervical spinal cord stimulator 
was medically necessary. The Plan denied your request. The Plan says the cervical spinal cord stimulator does 
not meet the Medicare NCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that a cervical spinal cord stimulator is covered when the 
criteria listed in the Medicare rules section of this decision 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 pay for a cervical spinal cord stimulator. Our 
reviewer says that a cervical spinal cord stimulator is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is no psychological evaluation documented in the chart. 
 
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 cervical spinal cord stimulator have not been met. Therefore, we decided that 
the Plan does not have to pay for a cervical spinal cord stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient T8-T9 Vertebroplasty (22515). 
 
You asked the Plan to pay for an outpatient T8-T9 Vertebroplasty. You say that the enrollee has back pain and 
a lumbar issue. The Plan denied your request. The Plan says medical necessity coverage criteria is not met as 
the pain is multifactorial with multilevel disc disease in the lower thoracic spine. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria in the rules 
section of this letter 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 pay for an outpatient T8-T9 Vertebroplasty. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that detailed 
documentation is not evident regarding acute/subacute T8 and T9 fractures. There is no indication of a 
progression of the body height loss or a severe impact on daily activities. Moreover, there is MRI corroboration 
of retropulsion and other plausible causes of pain. Therefore, the enrollee does not meet LCD coverage criteria. 
 
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 outpatient T8-T9 Vertebroplasty have not been met. Therefore, we decided 
that the Plan does not have to pay for an outpatient T8-T9 Vertebroplasty (22515).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device (22867) and a laminectomy (63005). 
 
You asked the Plan to pre-approve the Coflex device and a laminectomy. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requested services are 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 Coflex device and a laminectomy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Coflex device is experimental. More research is needed. 
 
   
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 Coflex device and a laminectomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Coflex device (22867) and a laminectomy (63005).
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for a specialist visit. We decided that the Plan does not 
have to waive the copayment for an ER visit.  
 
You asked the Plan to waive the copayment for an ER visit and a specialist visit provided from April 7, 2023, 
to April 9, 2023. You say that all the services provided should be included in the enrollee's emergency care 
visit. The Plan says that this cost sharing was charged correctly. We decided that the Plan has to waive the copayment for a specialist visit.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). Your contract with the Plan states that you must pay a $90 
copayment for an ER visit but does not specify that you should expect to pay a copayment for physician visits 
in addition to an ER copayment. Therefore, we decided that the Plan has to waive the copayment for a 
specialist visit.  
 
We also decided that the Plan does not have to waive the copayment for an ER visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for an ER visit. Therefore, we decided that the Plan does not have to waive the copayment for an 
ER visit. 
 
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines 
for services in an IRF.  
 
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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device (22867). 
 
You asked the Plan to pre-approve the Coflex device. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested Coflex lumbar interspinous decompression device is unproven and 
not medically necessary due to insufficient evidence of efficacy. 
 
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 Coflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence-based medical guideline and peer-reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for your 
medical condition. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception to guidelines. 
 
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 Coflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Coflex device (22867).
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, power lift) and upgraded electronics. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee is unable to perform independent weight shifts and has become weaker, putting the enrollee at high 
risk for skin 
breakdown. You also say that the enrollee qualifies for positioning skin protection cushions. The Plan denied 
your request. The Plan says the enrollee does not have a medical need for a Group 3 power wheelchair with tilt 
and recline. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered if 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 documentation does not support 
that the enrollee is high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. The reviewer also found that the enrollee has sufficient strength 
and function in upper extremities to manage standard power drives. Therefore, the reviewer found that the 
requested Group 3 power wheelchair and upgraded electronics are 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, power lift) and upgraded electronics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Barrett's esophagus assay provided on January 31, 2023. 
 
You asked the Plan to pay for the testing. 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested testing is not endorsed by national clinical guidelines and is not medically necessary in this scenario. 
 
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 pay for the Barrett's esophagus assay provided on January 31, 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 are requesting reconsideration for the denial of 
an IRF admission. 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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 admission to IRF will reduce risk for further re-
admissions for the enrollee. The Plan denied your request. The Plan says the enrollee's records do not show that 
your rehab needs are complex. The Plan says that the services needed may be provided safely in a lower level 
of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (0326U) provided September 23, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the decision that 
Guardant360 test is experimental and investigational and is requesting processing of the claim in network since 
you are the only servicing provider for Guardant360. The Plan denied your request. The Plan says the records 
do not support the service 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 code 0326U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, 
gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
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 service. Our reviewer says that the records do 
not support that the criteria has been met. Our reviewer found the medical record provided notes the collection 
date as September 16, 2022, therefore the billed date of September 23, 2022, is not accurate. Also, the medical 
records do not include an order and report for September 23, 2022, therefore this service cannot be verified. 
 
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 service have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing (0326U) provided September 23, 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 are unable to care for yourself and would need 
additional services. The Plan denied your request. The Plan says the required services can be provided in an 
alternate setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2023 to May 20, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 23, 2023 to May 20, 2023.