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

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on  
December 28, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the Plan requires utilization of network providers when 
possible and available and requires authorization for certain services. No medical necessity for an  
out-of-network provider such as an urgent or an emergent situation that has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on 
December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service February 
14, 2023. 
 
You asked the Plan to pay for procedure code(s) 88305. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service February 14, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the provided records support the 
medical necessity of this procedure. The Plan denied your request. The Plan says this procedure 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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided medical records and review of the current peer-reviewed medical 
literature do not document that use of the Intracept procedure has been shown in controlled studies in a CMS-
approved journal to result in long term health benefits in those with chronic low back pain. The reviewer found that additional study is needed to validate any benefit of this procedure, and to compare it to other 
interventions. Current medical literature indicates that the Intracept procedure is investigational at this time. 
Therefore, the reviewer found that the Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (L7520) provided on January 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 L7520 is "Repair prosthetic device, labor component, per 
15 minutes". 
 
We find that CPT code L7520 is not supported in the medical record. Specifically, the records do not show that 
time spent provided the services in question. Without documentation of the time spent, the billed code and units 
are not supported. 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 the services (L7520) provided on 
January 21, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on September 6, 2022, to 
September 23, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documentation establishes a clear link between sepsis and atrial fibrillation. The Plan denied your request. The 
Plan says that the diagnosis codes are not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with primary diagnosis code A41.9, defined as sepsis, unspecified 
organism; and secondary diagnosis code R65.20, defined as severe sepsis without septic shock. 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 the inpatient hospital services at the DRG originally billed. 
Our physician reviewer found that the enrollee had a history of type 1 diabetes with diabetic ketoacidosis and 
atrial fibrillation with rapid ventricular rate. He was found to have osteomyelitis and was treated with broad 
spectrum antibiotics. The patient had sepsis with bone as the infectious source with severe disease, thus meets 
codes A41.9 and R65.20. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on September 6, 2022, to September 23, 2022, at the Diagnosis Related 
Group (DRG) originally billed.  
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Northera. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Northera.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the CPAP device cleaner purchased on 
September 23, 2022. 
 
You asked the Plan to provide reimbursement for the CPAP device cleaner. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this item does not serve a 
medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to provide reimbursement for the CPAP device cleaner purchased on 
September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the VIA Disc procedure. You say that  the enrollee has suffered from 
midline lumbar pain. The Plan denied your request. The Plan says the VIA Disc procedure 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 VIA Disc procedure. Our reviewer 
says that the VIA Disc procedure is not medically necessary. Our physician reviewer found that the enrollee 
has chronic low back pain that radiates to the right lower extremity. The enrollee has tried medications, 
physical therapy, epidural steroid injections, and radiofrequency ablation which have not provided relief.  
However, the requested Via Disc procedure is considered experimental and investigational. 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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VIA Disc procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is not safe for you to go home at this time, and you 
need more therapy than is available at a skilled nursing facility. The Plan denied your request. The Plan says 
the IRF services you requested do not meet the requirements for approval.  
 
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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you can barely walk and have nerve pain in your leg. 
You feel if you do not have therapy right now, your condition will worsen. The Plan denied your request. The 
Plan says that you do not meet the requirements for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that, overall, the medical record significantly complies with the various documentation requirements for 
IRF admission. Your condition is in fact complex, and there is every reason to expect that you will participate 
in and benefit from services to include at a minimum physical therapy, occupational therapy, and physician 
oversight of pain control and wound care, as well as case manager coordination of any additional services that 
might be needed at home. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
an IRF admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy.  
 
You asked the Plan to pre-approve Hyperbaric Oxygen Therapy. You say that Hyperbaric Oxygen Therapy is 
medically necessary. The Plan denied your request. The Plan says the requested Hyperbaric Oxygen Therapy 
does not meet the Medicare NCD coverage criteria. The Plan follows Medicare rules. Medicare rules say that Hyperbaric Oxygen Therapy is covered when the 
criteria listed in the Medicare rules section of this decision 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 Hyperbaric Oxygen Therapy. Our 
reviewer says that the requested Hyperbaric Oxygen Therapy is not considered medically necessary. Our 
physician reviewer found the enrollee with a past medical history of hypertension, hyperlipidemia, and 
squamous cell carcinoma of the right tonsil. The carcinoma was treated with radiation, and the enrollee 
subsequently developed exposure of the medial surface of the right mandible with suspected 
osteoradionecrosis. The enrollee has not had any tissue or radiographic evidence of osteoradionecrosis. On 
April 24, 2023, the enrollee was seen by his provider and at that time was placed on antibiotics. On  
May 18, 2023, his provider reported improvement of the ulceration since being placed on antibiotics. The 
review has determined that the records do not show radiographic evidence of osteoradionecrosis and a failure 
of standard therapy. The requested Hyperbaric Oxygen Therapy does not meet the Medicare NCD 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 Hyperbaric Oxygen Therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Hyperbaric Oxygen Therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 requested item or service was exhausted on date of service February 18, 2019. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 24 routine acupuncture services. 
 
You asked the Plan to pre-approve 24 routine acupuncture services. You say that it is medically necessary The 
Plan denied your request. The Plan says that the requested service does not meet the Medicare or health Plan 
coverage criteria. 
 
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 did not provide any documentation to support that the benefit for 24 
routine acupuncture visits in the plan year had been exhausted. Without this necessary documentation, the Plan 
has not substantiated their denial reason.  Therefore, we decided that the Plan has to pre-approve 24 routine 
acupuncture services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient evaluation and management (EM) services 
provided on November 2, 2022, billed with code 99223. 
 
You asked the Plan to pay for the inpatient evaluation and management (EM) services provided. You say that 
the claim was billed correctly and should be paid. The Plan denied your request. The Plan says the level of care 
is not supported 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our physician 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 inpatient evaluation and management (EM) services 
provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the 
enrollee is a 75-year-old male who was seen on November 2, 2022, for shortness of breath. The documentation 
from that date describes the enrollee as short of breath without chest pressure or palpitations, cough or fever or 
other symptoms. He was hypoxic and required bilevel positive airway pressure. in the emergency department 
which was later removed. History was an expanded problem focused history. Physical findings were also 
expanded problem focused and brief. Vitals were stable on supplemental oxygen via nasal cannula and after 
initiation of Lasix for diagnosed acute on chronic congestive heart failure. Labs were otherwise unremarkable 
of other acute conditions. However, code, 99223, is not sufficiently supported as the documentation did not 
clearly support a comprehensive history and physical, nor did it support medical decision-making of high 
complexity.  
 
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 inpatient evaluation and management (EM) services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for inpatient evaluation and management (EM) 
services provided on November 2, 2022, billed with code 99223.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for your rehabilitation 
needs. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an 
IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.