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

 
We decided that the Plan has to pay for the shoulder orthosis provided on December 28, 2022. 
 
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that the documentation 
submitted did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the documentation submitted did not sufficiently support 
the billed supply code. However, the records contain an itemized packing slip dated December 26, 2022, with 
the same tracking number as the delivery ticket dated January 6, 2023. As such, the records support that the 
items at issue in this case were delivered. Therefore, we decided that the Plan has to pay for the shoulder 
orthosis provided on December 28, 2022.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee continues to experience 
poor drug response. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that transcranial magnetic stimulation is only covered 
under certain medical indications.  The file shows that 20 units of transcranial magnetic stimulation was requested. 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 requested services. Our physician reviewer found that in this 
case, the enrollee does have a diagnosis of major depressive disorder. The medical records that are available for 
review do not clearly support that the enrollee has had a lack of clinically significant response to four trials of 
psychopharmacologic agents in the current depressive episode.  Additionally, there is no clear documentation 
that states the member has been cleared medically for TMS. Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transcranial magnetic stimulation (TMS) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee has no daily skilled nurse or therapist needs. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the chest and a 
magnetic resonance imaging (MRI) of the neck. 
 
You asked the Plan to pre-approve the CT of the chest and the MRI of the neck. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the requested services do not meet the 
Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs and 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 of the chest and the MRI of the 
neck. Our reviewer says that the services are not medically necessary. Our physician reviewer found that 
during the gastroenterology encounter on February 15, 2023, the plan of evaluation was for an MRI of the 
abdomen and a magnetic resonance cholangiopancreatography. There is no mention of any physical finding or 
any symptom to justify an MRI of the neck and CT of the chest.  These should be denied as medically 
unnecessary. 
 
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 of the chest and the MRI of the neck have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computed tomography (CT) of the chest and a magnetic 
resonance imaging (MRI) of the neck.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc 850 (J7320). 
 You asked the Plan to pre-approve Genvisc 850. You say that the requested drug is necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc 
or Supartz FX. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Genvisc 850. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed the preferred drugs, Orthovisc or Supartz FX. The reviewer found that 
the documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or would 
likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Genvisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc 850 (J7320).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to regain maximum prior level of function. The Plan denied your request. The Plan says the enrollee's 
medical needs are being met in the current setting. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that this scan could differentiate between 
Alzheimer's Disease and frontotemporal dementia. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the service 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on November 22, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says that the code used to report the services provided is not 
supported in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the medical records support that 
drugs from 20 drug classes were tested in this case. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on November 22, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of pain in this enrollee is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the requested ESI. You say that this should be allowed. The Plan denied 
your request. The Plan says the enrollee's pain and functional improvements did not last long enough to warrant 
repeat ESI. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered reasonable and 
necessary when the prior injection produced 50% relief for at least 3 months. 
 
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 requested ESI. Our reviewer says 
that the requested ESI is not medically reasonable and necessary. Our physician reviewer found the enrollee is 
a female with chronic low back pain. She underwent a lumbar interlaminar ESI on February 17, 2023, at the 
L5-S1 level. She had 50% pain relief for 3 weeks. The physician has requested to repeat the same procedure at 
the same level using the same approach. The LCD requires at least 50% pain relief for 3 months. This was not 
achieved, and the physician wishes to repeat the ESI at the same level and same approach. Therefore, the 
request is deemed not 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 requested ESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat lumbar epidural steroid injection (ESI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 24, 2022, to 
July 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 24, 2022, to July 
23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on April 6, 2022. 
 You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this service is included in payment for 
code 93000. 
 
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 93010-76 is a column II code to column I code 93000; however, 
93010-76 was billed with a modifier.  
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the medical record includes two 
electrocardiogram reports, however the interpretation and report is included in the routine electrocardiogram. In 
this case, code 93010 cannot be verified as a separate distinct service. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on April 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 15, 2022, 
to February 16, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that, on Medicare claims, these HHRGs are represented as 
Health Insurance Prospective Payment System (HIPPS) codes. 
 
We looked at the file and Medicare rules. The file shows that the records do not support the billed HIPPS code. 
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 home health services rendered from February 
15, 2022, to February 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from November 23, 2021, 
to December 22, 2021. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that, on Medicare claims, these HHRGs are represented as 
Health Insurance Prospective Payment System (HIPPS) codes. 
 
We looked at the file and Medicare rules. The file shows that the records do not support the billed HIPPS code. 
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 home health services rendered from November 
23, 2021, to December 22, 2021.
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. The Plan denied your request. The Plan says the information does 
not meet all of the requirements, the present time, the enrollee's condition requires ongoing medical care in the 
current setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on June 14, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance providers must bill a QM or QN 
modifier to describe whether the service was provided under arrangement or directly. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required QM or 
QN modifier. 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 ambulance transport rendered on 
June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the viable disc nucleus pulposus (NP) tissue allograft 
(0627T) with the trade name Via Disc NP. 
 
You asked the Plan to pre-approve the Via Disc NP. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this procedure is considered experimental. 
 
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 Via Disc NP. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is considered experimental. 
 
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 Via Disc NP have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the viable disc nucleus pulposus (NP) tissue allograft (0627T) with the trade name Via 
Disc NP.