Persius/hicric huggingface dataset:
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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on the available information, 
admission to IRF is not reasonable and necessary, as the enrollee's condition does not meet thee Medicare rules.  
 
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. The enrollee 
was admitted for encephalopathy and urinary tract infection. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen based wound filler provided on September 19, 
2023. 
 
You asked the Plan to pay for collagen based wound filler. You say that this service is supported in the records. 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 collagen based wound 
filler provided on September 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of the intraosseous basivertebral 
nerve (Intracept procedure).  
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are requesting reconsideration 
based on medical necessity. 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found there are multiple plausible pathologic sources of significant pain generation. 
The chronic lumbar pain, the noted pain-aggravating factors (prolonged sitting as well as prolonged standing 
activity), pain-relieving factors (rest and medication), and intact neurologic exam are all non-specific to any 
pathologic entities. The documentation is lacking regarding reasonably detailed or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. The documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary or reasonable at this time. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L3, L5, and S1, in this case, 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 thermal destruction of the intraosseous basivertebral nerve (Intracept 
procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 24, 2023, billed with 
procedure code P9603. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says required documentation has not been provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, no medical records have been provided for review. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on July 24, 2023, billed with procedure code P9603.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service August 11, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the testing was needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 83789 billed for date of service August 11, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Byooviz. 
 
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 Eylea. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug. The reviewer also found that there is no indication that 
the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) skilled nursing visits and nine (9) physical 
therapy home health visits. 
 
You asked the Plan to pre-approve home health services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation doesnt support that the enrollee requires additional skilled nursing services or skilled rehab 
services to provide treatment that is medically necessary. The enrollee does not require additional skilled 
nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the 
enrollees condition, perform a maintenance program to maintain the members condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health services 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four (4) skilled nursing visits and nine (9) physical therapy home health visits.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 93458, 75898, 92928 and 
99152. We decided that the Plan does not have to pay for the services described by procedure code(s) 99153.  
 
You asked the Plan to pay for the cardiovascular services described by codes 93458 and 92928, the radiology 
services described by code 75898, and the moderate sedation services described by codes 99152 and 99153 
performed on August 9, 2023. You say that 93458, 92928,75898, 99152, and 99153 should be paid as billed 
because they are supported in the documentation. The Plan says that 93458, 92928,75898, and 99152 are being 
handled as an original decision reopen for New and Material Evidence, therefore no coverage decision has been 
made. 99153 is denied because this code is not payable in the facility setting. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 93458, 75898, 92928 
and 99152.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 93458, 75898, 92928 and 
99152.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99153. 
 
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE 
only code and that PE are not payable to the physician for services provided in the facility setting. 
 
We looked at the file and Medicare rules. We find that payment for CPT code 99153 is not supported. 
Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility 
setting. Based on this information, we decided that Medicare rules for coverage of the services described by 
procedure code(s) 99153 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 99153. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service June 17, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says you disagree with the Plan's denial. 
 
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 procedure code 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented with an abscess of his right buttocks, which underwent incision and drainage. The documentation 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 procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service June 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single power option 
(tilt, legrests) and captain's chair. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with single power option. You say that the 
enrollee's current power wheelchair is more than 5 years old. You also say that it is no longer medically 
appropriate for the enrollee. The Plan denied your request. The Plan says there is no medical need for the 
requested power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 power wheelchair with single power option 
may be covered when the coverage 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 Group 2 power wheelchair with single 
power option. Our reviewer says that the requested Group 2 power wheelchair with single power option is not 
medically necessary. Our physician reviewer found the provided records indicate that the enrollee does not 
have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means 
of managing power drive. The reviewer also found that the enrollee does not use a ventilator. Therefore, the 
reviewer found that the requested Group 2 power wheelchair with single power option 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 a Group 2 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single 
power option (tilt, legrests) and captain's chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trospium Chloride. 
 
You asked the Plan to pre-approve Trospium Chloride. You say that the medication is medically 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 Trospium Chloride. Benefits for Trospium Chloride 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 for date of service April 18, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services billed 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 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 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 procedure code 99285. Our reviewer says that the 
documentation supports the code billed. Our reviewer found the enrollee presented to the Emergency Room 
with abdominal pain and nausea. The enrollee required a comprehensive work up which did not reveal acute 
findings. The enrollee improved with Emergency Department intervention and was discharged. The enrollee 
was suspected of having viral gastroenteritis. This is an example of an acute uncomplicated problem. Although 
this was an acute uncomplicated problem, the documentation supports that admission was considered. This 
consideration changes risk level to high. Additionally, the medical decision-making was very thorough. All in 
all, documentation supports a medically appropriate history and exam as well as high level of documentation. 
Therefore, code 99285 is supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99285 for date of service April 18, 2023.  
 
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: 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 medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies as an 
outpatient or at home with home healthcare 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 needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve Myrbetriq. You say that the medication is medically 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 Myrbetriq.  Benefits for Myrbetriq may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.