Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical laminectomy procedure. 
 
You asked the Plan to pre-approve a cervical laminectomy procedure. You say that the documentation provided 
supports the need for the services in dispute. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for coverage of the requested a cervical laminectomy procedure. 
 
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 cervical laminectomy procedure. Our 
reviewer says that the cervical laminectomy procedure being requested is not medically reasonable and 
necessary. Our physician reviewer found that the medical records demonstrate that the enrollee smokes 
cigarettes daily. Smoking significantly increases the risk of pseudoarthrosis for patients undergoing both 
lumbar and cervical fusions. In addition to nonunion, smoking also increases the risk of other perioperative complications such as infection, adjacent-segment pathology, and dysphagia. Our physician reviewer says that 
the requested surgical procedure is not meet the criteria of being safe and effective for this enrollee. Our 
physician reviewer says that more conservative measures are 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 cervical laminectomy procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a cervical laminectomy procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three out-of-network visits with oncology. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 
three out-of-network visits with oncology.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says with additional time in the current setting, clinical 
stability can be ensured such that the appropriate lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee underwent coronary artery bypass grafting following a non-ST elevation 
myocardial infarction. Their post-operative course included tracheostomy and percutaneous endoscopic 
gastrostomy (PEG) tube placement. They are now on tracheotomy collar and do not have complex wound care needs; thus, they do not meet LTACH admission 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device, single level (22867), and second level (22868). 
 
You asked the Plan to pre-approve the InSpan procedure. You say that this is necessary to provide longer 
lasting pain relief for the enrollee. The Plan denied your request. The Plan says this is experimental and 
therefore is not covered. 
 
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 InSpan procedure. Our reviewer 
says that the requested InSpan procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found interspinous process distraction devices are experimental in spinal surgery. 
Therefore, the reviewer found that the requested   
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 InSpan procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device, 
single level (22867), and second level (22868).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim Neo system and an inpatient stay. 
 
You asked the Plan to pre-approve Barostim Neo system and an inpatient stay. You say that this is medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the Barostim 
Neo System in the setting of congestive heart failure have not been demonstrated in the peer-reviewed 
literature. The Plan also says the requested inpatient hospital stay isn't covered because it's associated with a 
service that is denied. 
 
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 Barostim Neo System and an inpatient 
stay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found there remains an absence of studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient 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 Barostim Neo system and an inpatient stay have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Barostim Neo system and an inpatient stay.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on March 1, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
that the documentation supports an appropriate exam, but not an appropriate history or medical decision 
making of high level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on March 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve home health services. You say that you want to use this provider as they are 
within at half mile radius from your home. You also say that they provide excellent service. The Plan denied 
your request. The Plan says there are network providers available. 
 
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 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OrthoFix Trinity Elite allograft (20930) and bone 
marrow aspirate (20939). 
 
You asked the Plan to pre-approve the OrthoFix Trinity Elite allograft and bone marrow aspirate. You say that 
the enrollee has severe compression of the nerves in the setting of a previous fusion. You say in order to fully 
decompress the nerves, the enrollee needs an extension of their fusion. The Plan denied your request. The Plan 
says the request 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 OrthoFix Trinity Elite allograft and 
bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to 
support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-
term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical 
condition. Additionally, there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. No 
compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested OrthoFix Trinity Elite allograft and bone marrow aspirate 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 OrthoFix Trinity Elite allograft and bone marrow aspirate have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the OrthoFix Trinity Elite allograft 
(20930) and bone marrow aspirate (20939).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is currently unstable for a transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the Plan. Given there are offered alternatives, an LTACH admission 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you still have goals to meet before you can transfer 
safely home. The Plan denied your request. The Plan says you are receiving adequate and necessary intensive 
rehabilitation in the inpatient rehabilitation facility (IRF). 
 
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 you are primarily limited by your weight bearing status and require at least moderate 
assistance with mobility and daily activities. While you continue to require assistance with mobility and daily 
activities, it is unclear why you require the degree of medical and nursing oversight provided in a skilled 
nursing facility. You are making progress with therapies and can be discharged home with home health 
services. Therefore, the skilled nursing facility care 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on March 22, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
that the documentation supports a medically appropriate history and examination but does not support a high 
level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on March 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional home health aide (HHA) services. 
 
You asked the Plan to pre-approve the additional aide services. You say that you are desperately in need of the 
84 hours to be well equipped and well supported around the clock to help you witj the various medical issues. 
You also say that you are a fall risk all the time.  The Plan denied your request. The Plan says the services are 
not medically necessary.  
 The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional aide services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
clinical documentation dated January 2, 2024 indicated that you were seen for a 3-month follow-up. Your  
chronic obstructive pulmonary disease (COPD) is noted to be stable as well as your chronic pain. You are 
receiving in home physical therapy and are ambulating with the assistance of a walker or cane. An assessment 
of your activities of daily living indicates that you require 38.5 hours per week in personal care hours. 
Therefore, the additional home health aide assistance 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 the additional aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the additional home health aide (HHA) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 wheelchair and accessories. You say that the enrollee has gross 
upper and lower extremity weakness. A lower group power chair would not be able to support all the power 
functions the enrollee needs. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
the requested device and accessories. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 1, 
2022, to November 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the record did not show that at the time of inpatient admission the 
admitting physician would reasonably have expected that the enrollee's necessary hospital care would span two 
midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided records indicate that the enrollee presented to the emergency department 
(ED) with report of fall, hitting their head. Neurological examination revealed no focal deficits, and the 
enrollee was alert and oriented. The reviewer found that the computed tomography (CT) head negative for 
acute abnormalities. The enrollee had stable vitals, and workup otherwise negative. At the time of admission, 
the enrollee was not expected to have an adverse event or require hospital service that would likely cross 2 
midnights for additional workup and treatment. Therefore, the reviewer found that the inpatient hospital care 
was 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from November 1, 2022, to November 
3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray 
(D0220) provided on July 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have seen this provider on multiple 
occasions. You say that the provider is not listening to you and not trying to get to the root of your issue. You 
also say that you would not have required another check-up if that was the case. 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 the limited oral evaluation was exhausted on date of service January 19, 2023, and your benefit for periapical x-ray was exhausted on date of service July 6, 2023. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on July 31, 
2023.