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 the services are medically necessary for the enrollee 
to regain their independence. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to 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 treatment by multiple therapies. While the medical 
record supports a need for physical 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 you need inpatient rehab so that you can regain your 
maximum level of function. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist telehealth visit provided on 
April 20, 2023. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you were unable to 
go into the office, and do not feel you should have to pay for this telehealth visit. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $10 copayment for the specialist telehealth visit. This item/service falls within 
the in-network specialist physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. The Plan contract says that the specialist office visit 
copayment applies to in-person or telehealth visits. Therefore, we decided that the Plan does not have to waive 
the copayment for the specialist telehealth visit provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that you disagree with the denial 
and are requesting reconsideration. The Plan denied your request. The Plan says there is not enough medical 
proof that shows the safety and/or success of this treatment, so it is considered experimental and/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 genicular radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has osteoarthritis of the left knee. He has done physical therapy 
and has had two diagnostic blocks of the genicular nerves, each of which produced 80% pain relief. This is 
considered an experimental/ investigational procedure. It is the subject of ongoing clinical trials. Therefore, the 
request is deemed 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 genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including 
imaging guidance (64624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee uses Prolia because she is on Prednisone 
for Rheumatoid arthritis. The Plan denied your request. The Plan says the enrollee does not have documented 
osteoporosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Prolia. Our physician reviewer found 
that the enrollee has a diagnosis of osteopenia. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the 
coverage criteria are not satisfied.  The requested service cannot be 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on March 8, 2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you need the portable oxygen concentrator 
to travel and leave the house. You also say that according to your plan you should receive 50% of the purchase 
price when purchased from an out-of-network vendor. The Plan denied your request. The Plan says this item 
was purchased through a provider that is not enrolled in Medicare. 
 
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 the oxygen concentrator (E1390) provided on March 
8, 2023.  
 
Your complaint about the DME provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the wound care services provided on 
February 23, 2023, by an OON provider.  
 
You asked the Plan to pay for an office visit and the wound care services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this service was not 
authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and the wound care services 
provided on February 23, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement power wheelchair (K0835) and accessories 
(E1002 power seating system, tilt only; E1012 addition to power seating system, center mount power elevating 
leg rest/platform, complete system; E2311 electronic connection between wheelchair controller and 2 or more 
power seating system motors).  
 
You asked the Plan to pay for the replacement power wheelchair and accessories. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee's 
wheelchair has been lost or irreparably damaged from a specific accident or natural disaster. Replacement due 
to wear is not covered within the reasonable useful life of the equipment (which can be no less than 5 years); 
the enrollee received their wheelchair 1 year ago. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover 
repair up to the cost of replacement (but not actual replacement) for medically necessary equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement power wheelchair and accessories have not been met. Specifically, there is no 
justification as to why the wheelchair requires replacement or whether the enrollee's power wheelchair could be 
repaired, and how much it would cost to repair the current wheelchair. Therefore, we decided that the Plan does 
not have to pay for the replacement power wheelchair (K0835) and accessories (E1002 power seating system, 
tilt only; E1012 addition to power seating system, center mount power elevating leg rest/platform, complete 
system; E2311 electronic connection between wheelchair controller and 2 or more power seating system 
motors).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 21, 2023, billed with 
procedure codes 99213-25, J2001-59, 76881-59, and 76942-59. 
 
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 documentation does not support the billed codes. 
 
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 codes 99213-25, J2001-59, 76881-59, and 76942-59 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 low level of medical decision making. When using time 
for code selection, 20-29 minutes of total time is spent of the date of the encounter (99213), injection, lidocaine 
for intravenous infusion, 10 mg (J2001), ultrasound, complete joint (ie, joint space and periarticular soft-tissue structures), real-time with image documentation (76881), ultrasound guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device), and imaging supervision and interpretation (76942). 
 
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 not support the billed codes. Our reviewer found that the procedure report does not support 
code 99213 appended with modifier 25 as the evaluation and management service is related to the procedure 
performed. Code J2001 is not supported as procedure report describes lidocaine injection, however intravenous 
infusion was not documented in the procedure report and therefore cannot be verified. The procedure report 
does not include documentation of a complete joint ultrasound, code 76881 is not supported. Procedure report 
describes knee injection with ultrasound guidance, however procedure 76942 reported with modifier -59 to 
bypass NCCI Edit with CPT 76881 cannot be verified as procedure was not documented. 
 
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 not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 21, 2023, billed with procedure codes 
99213-25, J2001-59, 76881-59, and 76942-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic office visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the orthopedic office visit. You say that you would like a second opinion 
from a new specialist. The Plan denied your request. The Plan says there are network providers that can 
provide these services. 
 
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 
the orthopedic office visit to be provided by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing for cancer (81432, 81433). 
 
You asked the Plan to pre-approve genetic testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says that the documentation provided does not support that the enrollee meets 
the criteria for coverage of this testing, as the records are not clear regarding how this testing will impact the 
enrollee's treatment. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a personal history of breast cancer, stage IIB, recently diagnosed. Her father 
died at 46 from lung cancer as did her two siblings. Her mother, an only child, lived to age 96. She has 1 child, 
a daughter aged 50, with no malignancy. She has 2 brothers with no children. Per the National Comprehensive 
Cancer Network (NCCN) Guidelines, individuals with unknown or limited family history/structure, such as 
fewer than 2 female first- or second-degree relatives having lived beyond age 45 in either lineage, may have an 
underestimated probability of familial germline pathogenic/likely pathogenic variant detection. Given limited 
female relatives on the paternal side and the age of her father's death coupled with her mother being an only 
child, this enrollee meets criteria for testing. The service is reasonable and 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 genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve genetic testing for cancer (81432, 81433).  
 
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 the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that they need an intensive team for their 
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 there are no acute rehab nursing needs identified or documented. The complexity of 
the enrollee's medical, rehab, and nursing needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. The enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing facility or-in-home with 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three-dimensional (3-D) interpretation and report 
performed on March 30, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 3-D rendering 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found there is no documentation of an order for 
the 3-D imaging nor documentation by the rendering physician that the 3-D interpretation was medically necessary. The use of 3-D rendering with interpretation and reporting of computed tomography, magnetic 
resonance imaging, or other tomographic modality with image post processing is not covered separately by 
Medicare as it is contained in the authorized radiologic procedure. 
 
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 pay for the three-dimensional (3-D) interpretation and report performed on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuropsychological testing evaluation services provided on 
April 26, 2022, to November 9, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for neuropsychological testing evaluation services. You say that you weren't aware 
the claims were being denied. The Plan denied your request. The Plan says there are no referrals for out-of-
network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for neuropsychological testing evaluation services 
provided on April 26, 2022, to November 9, 2022, by an out-of-network (OON) provider.