Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kenevo advanced electronic knee. 
 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 knee prosthesis accessories 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Kenevo knee has features that 
exceed the enrollee's functional needs, such as intuitive indoor bicycle function. There is no evidence that the 
enrollee participates in indoor cycling. The documentation does not support extenuating factors that indicate 
that the enrollee's functional needs require this microprocessor Kenevo advanced knee or that this enrollee's 
functional needs require a microprocessor knee over a mechanical knee. The services are therefore not 
reasonable or 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 Kenevo advanced electronic knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to 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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found hyperbaric 
oxygen therapy is not medically necessary. The enrollee had a diabetic foot wound, Wagner 4 with partial 
gangrene, which did not heal and progressed to necrosis after transmetatarsal amputation. Shortly after the 
request for HBO therapy, the enrollee underwent a below the knee amputation, so HBO is no longer 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 HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision (99183).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from 
October 27, 2021, to October 31, 2021. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. The documentation available 
for review that pertains to the appropriate look-back period does not support that the member had an active 
diagnosis of pneumonia and diabetes mellitus that required a treatment plan that was signed by a physician. 
The 3rd and 4th alphanumeric character in the PDPM were not correct. The partial adjustment to PDPM 
KDXF1 was appropriate. 
 
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 skilled nursing facility (SNF) services rendered from October 27, 2021, to October 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support this patient meets the 
full criteria for an inpatient rehabilitation stay. The Plan denied your request. The Plan says the member does 
not meet the Medicare criteria for admission to an inpatient rehabilitation facility (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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lethargy, a fall, and acute renal failure. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical records support 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92507 billed for date of service October 15, 
2022.   
You asked the Plan to pay for procedure code 92507. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 92507 is 1 per date of service. The MAI value for this code is 3. You billed 
2 units of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess 
units were actually provided, were correctly coded, and were medically necessary. Based on this information, 
we decided that Medicare rules for coverage of procedure code 92507 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 92507 billed for date of service October 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stereotactic body radiation therapy (SBRT), 
treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 
fractions (77373). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no good evidence the SBRT treatment is safe or effective or best for 
the enrollee's cancer. The Plan states the SBRT is not medically necessary and other kinds of radiation would 
be 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records describe a biopsy of a left upper lobe lung mass which showed no evidence of 
cancer. It is unclear why two (2) bone lesions would be treated with SBRT as there are no imaging records 
suggestive of bone metastases, and the History of Present Illness (HPI) suggest uncertainty in the diagnosis 
presumably based on whether or not the lung mass was a metastasis. Our physician reviewer's decision is 
unfavorable as SBRT would not be standard of care for patients with questionable or no bone metastases.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the stereotactic body radiation therapy (SBRT), treatment delivery, per fraction to 1 or 
more lesions, including image guidance, entire course not to exceed 5 fractions (77373).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional units of ostomy skin barrier (A4409). 
 
You asked the Plan to pre-approve additional units of ostomy skin barrier. You say that you are confident that 
providing the enrollee with additional ostomy supplies would greatly increase their quality of life and help 
them better manage their ostomy. The Plan denied your request. The Plan says based on the policy criteria 
provided, the maximum allowed quantity is 20 units per month, and this amount was approved for the enrollee. 
The Plan also says that additional units of the ostomy skin barrier is considered 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 additional units of ostomy skin barrier. 
Our reviewer says that the additional ostomy skin barrier is not medically necessary. Our physician reviewer 
found the enrollee has undergone multiple parastomal hernia repairs. They were evaluated on February 15, 
2023, regarding their ventral hernia and was noted to have a colostomy with a with an associated parastomal 
hernia with a couple of small bowel loops. Our reviewer also found that the enrollee requires ostomy skin 
barrier, for which 20 units have been approved, but it is unclear why they clinically require the additional 
ostomy skin barrier. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional units of ostomy skin barrier have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional units of ostomy skin barrier (A4409).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) office visits (99202, 99212) with a cardiac 
electrophysiologist to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that you just came out of the hospital and was referred 
to this doctor. You need this procedure so that you do not continue to have heart attacks. The Plan denied your 
request. The Plan says you must receive care from an in-network provider. The services can be rendered by an 
in-network provider with the Plan. 
 
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 
two (2) office visits (99202, 99212) with a cardiac electrophysiologist to be provided by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (99183, G0277) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you need the requested therapy as 
part of your treatment, as this will improve and help you recover your hearing due to sudden hearing loss. The 
Plan denied your request. The Plan says you must use network provider for most medical services. The service 
requested is available in-network. 
 
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 
hyperbaric oxygen therapy (99183, G0277) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a touch screen joystick color remote (K0108), pulse mechanical switch (K0108), and head rest swing away adjustable switch mount (K0108).

You asked the Plan to pre-approve a touch screen joystick color remote, pulse mechanical switch, and head rest swing away adjustable switch mount. You say that these accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says the requested features are unbundled and cannot be approved.

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 touch screen joystick color remote, pulse mechanical switch, and head rest swing away adjustable switch mount. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the expandable control allows a variety of means of alternative control. The specific type of alternative control available through the controller is not specified and included in the billing for the expandable controller. All hardware for the expandable controller is included in the coding for the expandable controller. The medical necessity for a touch screen control is not addressed in the records.

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 touch screen joystick color remote, pulse mechanical switch, and head rest swing away adjustable switch mount have not been met. Therefore, we decided that the Plan does not have to pre-approve a touch screen joystick color remote (K0108), pulse mechanical switch (K0108), and head rest swing away adjustable switch mount (K0108).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network psychiatrist. 
 
You asked the Plan to pre-approve these services. You say that you would like to see this provider. The Plan 
denied your request. The Plan says the services are available from 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 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 
a referral to an out-of-network psychiatrist.
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 would benefit for inpatient rehabilitation 
services both in therapy and medical management. The Plan denied your request. The Plan says an intensive 
rehabilitation program 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 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: 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 prefer to admit to acute rehabilitation because 
you were independent before hospitalization and want to return to being independent. The Plan denied your 
request. The Plan says you do not meet the Medicare criteria for admission to an Inpatient Rehabilitation 
Facility. 
 
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 is functioning very near a home care level of function. Intensive 
rehabilitation 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 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 the HBOT (99183 and G0277). 
 
You asked the Plan to pre-approve the HBOT. You say that the enrollee is in pain and the enrollee can get 
more infections if treatment is delayed making the enrollee's condition worsen.  The Plan denied your request. 
The Plan says the enrollee's records do not show physical exam findings consistent with soft tissue 
radionecrosis or osteoradionecrosis. 
 
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 HBOT. Our physician reviewer 
found the review has determined that the requested hyperbaric oxygen therapy is not medically necessary or 
reasonable. Physical exam findings consistent with soft tissue radionecrosis or osteoradionecrosis were not 
present. 
 
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 HBOT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the HBOT (99183 and G0277).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 You asked the Plan to pre-approve the additional non-emergency transportation trips. The Plan denied your 
request. The Plan says the transportation requested is in excess of the thirty-two (32), one-way trips was 
sustained on appeal. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
routine transportation trips. Based on this information, we decided that you have exhausted the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional non-emergency transportation trips (A0100).