Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on July 31, 2023, to 
September 18, 2023. 
 
You asked the Plan to pay for the psychotherapy (90837). You say that the service was medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the psychotherapy (90837) provided on July 31, 2023, to September 18, 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 an IRF admission is the enrollee's only chance at 
returning to a prior level of activity and independence. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, but skilled therapies as an outpatient or at a skilled nursing facility (SNF) 
may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on August 9, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that codes 0012M and 0013M for CxBladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the Cxbladder test (0013M) provided on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injection with moderate sedation.  
 
You asked the Plan to pre-approve the injection with moderate sedation. You say that the procedure requires 
delicate and precise placement of needles in the areas of the spine where severe complications can arise if a 
patient moves suddenly. You say that the procedure is quite painful, and it is unreasonable to subject patients to 
these procedures without appropriate comfort measures. The Plan denied your request. The Plan says the 
additional facet joint injection with moderate sedation 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 injection with moderate sedation. 
Our reviewer says that the additional facet joint injection with moderate sedation is not medically necessary. 
Our physician reviewer found that the learned societies of pain management have specifically stated that there 
is an increased risk of morbidity and mortality when sedation is used during pain procedures, and it also 
distorts the correct interpretation of the results. Also, the LCD limits the number of levels treated to three per 
session, the request exceeds that limit. Therefore, only two levels are medically reasonable and 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 injection with moderate sedation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the facet joint injection with moderate sedation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery (22633). 
 
You asked the Plan to pre-approve spinal fusion surgery. 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 lumbar spinal fusion surgery may be considered 
medically necessary and covered for certain indications. 
 
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 spinal fusion surgery. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no spinal instability 
fracture or lesion. Spinal fusion surgery is not 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 spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery (22633).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records show that the enrollee's upper limb strength 
and function are adequate to be able to control the power options using their own switches which are included 
in the allowance of these power options. 
 
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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided records indicate that the enrollee has adequate strength to manage 
standard power drives. Therefore, the reviewer found that the requested upgraded electronics are 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RUSH Chopart foot (L5976). 
 
You asked the Plan to pre-approve a RUSH Chopart foot. 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 lower limb prostheses 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 a RUSH Chopart foot. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the requested item exceeds the 
enrollee's medical needs. The treating medical nurse practitioner provider progress notes do not include details 
that indicate that the current Chopart foot is damaged, beyond repair, or is unable to be removed from old 
prosthesis attached to the new prosthesis. The Nurse practitioner addendum was almost 2 months after the last 
enrollee visit on November 21, 2023 and there is no evidence on this visit of a detailed in person evaluation of 
the prosthetic device. 
 
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 RUSH Chopart foot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a RUSH Chopart foot (L5976).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), oral/facial 
photographic images (D0350 x4), and oral hygiene instructions (D1330) provided on August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says your benefit for the panoramic radiographic image has already been exhausted. The 
oral/facial photographic images and oral hygiene instructions are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 panoramic radiographic image was exhausted on date of service August 14, 2023. 
Additionally, oral/facial photographic images and oral hygiene instructions are not covered benefits. Therefore, 
we decided that the Plan does not have to pay for the panoramic radiographic image (D0330), oral/facial 
photographic images (D0350 x4), and oral hygiene instructions (D1330) provided on August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the notes do not show a medical need to control the 
power options through the joystick. 
 
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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 

Our physician reviewer found an expandable controller is an electronic system that is capable of 
accommodating one or more additional features and can operate 3 or more powered seating options.  The 
requested electrical accessories are not medically necessary as the member does have use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Therefore, the reviewer found that the requested 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the chest. 
 
You asked the Plan to pre-approve the CT scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says records submitted show that you had a CT Angiography (CTA) scan of 
the chest on December 6, 2023, and a diagnostic bronchoscopy on December 21, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scan. Our reviewer says that the 
request is not medically necessary. Our physician reviewer found that a recent CT to exclude a pulmonary 
embolism (PE) was taken. Therefore, an additional CT scan is not warranted, especially since renal function 
may not tolerate. Also, there is a ventilation perfusion scan requested, which is a perfusion study for chronic PE 
or acute PE and may be substituted in these situations. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT scan of the chest.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Intraoral -Periapical First Radiographic Image (code D0220), 
Intraoral - Periapical Each Additional Radiographic Image (code D0230), Pontic - Porcelain Fused to Noble 
Metal (code D6242) and Core Buildup (code D2950) provided on August 15, 2023. 
 
You asked the Plan to pay for Intraoral -Periapical First Radiographic Image, Intraoral - Periapical Each 
Additional Radiographic Image, Pontic - Porcelain Fused to Noble Metal and Core Buildup. You say that your 
bridge broke and needed to be replaced and you were unaware some services may not be covered. The Plan 
denied your request. The Plan says there is no coverage for core build-up or pontic-porcelain fussed to metal. 
The Plan says that the benefit has been exhausted for Intraoral -Periapical First Radiographic Image, Intraoral - 
Periapical Each Additional Radiographic Image. 
 
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, the requested core build-up or pontic-
porcelain fussed to metal are not among those covered under this benefit. Additionally, the file shows that the 
benefit has been exhausted for Intraoral -Periapical First Radiographic Image, Intraoral - Periapical Each 
Additional Radiographic Image. Therefore, we decided that the Plan does not have to pay for Intraoral -
Periapical First Radiographic Image (code D0220), Intraoral - Periapical Each Additional Radiographic Image 
(code D0230), Pontic - Porcelain Fused to Noble Metal (code D6242) and Core Buildup (code D2950) 
provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin seal moisturizer (A6250) and skin barrier wipe 
(A5120) provided July 19, 2023, to August 16, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that the enrollee did not receive any procedure 
that would or should prevent payment, therefore, please evaluate the decision and pay accordingly. The Plan 
denied your request. The Plan says these items are not covered by Medicare 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Although these items may be appropriate, they do not fall into a 
covered benefit category and cannot be paid for by Medicare or the Plan. Based on this information, we 
decided that Medicare rules for coverage of the wound care supplies have not been met. Therefore, we decided 
that the Plan does not have to pay for the skin seal moisturizer (A6250) and skin barrier wipe (A5120) provided 
July 19, 2023, to August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says the epidural 
steroid injection 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 injection. Our reviewer says that the 
epidural steroid injection is not medically necessary. Our physician reviewer found that the enrollee has a 
history of chronic neck and low back pain due to cervical and lumbar spondylosis. However, it is not 
considered medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs at more than one 
level during the same session. Therefore, the enrollee does not meet the 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the additional epidural steroid injection.
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 learning to ambulate with a prosthetic can be very 
challenging if the enrollee cannot get intense therapy and work with a team and prosthetist during the initial 
onset of learning to use the new device. You say that a short rehab stay is much better than a prosthesis that sits 
in a closet when the enrollee is not able to get the training they need. The Plan denied your request. The Plan 
says an IRF admission 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 the enrollee needs rehabilitation services so they can 
get back in shape as they are not really able to sit up and they need to build their strength back up so they can 
go home and be independent. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, but skilled therapies as an outpatient or at a skilled nursing facility may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service November 
13, 2022.  
 
You asked the Plan to pay for procedure code 99232. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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, we have confirmed that code 99232 
is a column two code to column one code 99233 with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 billed for date of service November 13, 
2022.