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

 
We decided that the Plan does not have to pre-approve twist drill, burr hole, craniotomy, or craniectomy with 
stereotactic implantation of neurostimulator electrode array in subcortical site (61867, C1778). 
 
You asked the Plan to pre-approve twist drill, burr hole, craniotomy, or craniectomy with stereotactic 
implantation of neurostimulator electrode array in subcortical site. You say that this is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan follows Medicare rules. 
 
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 twist drill, burr hole, craniotomy, or 
craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site. Our reviewer 
says that the enrollee does not meet criteria for coverage. Our physician reviewer found the enrollee does not 
have a documented diagnosis of essential tremor with marked disabling tremor of at least level 3 or 4 on the 
Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale, or a diagnosis of advanced idiopathic 
Parkinson's disease as determined by the use of Hoehn and Yahr stage or Unified Parkinson's Disease Rating 
Scale (UPDRS) part III motor subscale, with persistent disabling Parkinson's symptoms or drug side effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation 
of neurostimulator electrode array in subcortical site have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of 
neurostimulator electrode array in subcortical site (61867, C1778).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are in the hospital waiting to be admitted to a 
skilled nursing facility. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary.  
 
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. The Plan denied your request. The 
Plan says the records do not show that the enrollee is unable to safely use a scooter. The Plan also says this 
request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 PWC (such as code K0823) is covered if all 
of the basic coverage criteria for a PWC are met and the wheelchair is appropriate for the beneficiarys weight. 
 
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 standard power wheelchair. 
Our reviewer says that is request is not medically reasonable and necessary. Our physician reviewer found the 
enrollee has had a stroke and has impaired mobility. The physician indicates the enrollee has adequate strength 
to manage a scooter. Our reviewer found that the enrollee has not had an evaluation indicating a group 2 power 
wheelchair is necessary. Our physician reviewer also found that the record does not support a group 2 power 
wheelchair and it does indicate a power scooter would be adequate for the enrollee's needs. 
 
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 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve application of skin substitute. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no recommendation or guidelines pertaining to post Mohs surgery skin 
grafts. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is necessary due to the location and potential for serious complications from a non-healing 
wound. This would otherwise require a reconstructive surgery. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve application of skin substitute.  
 
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 pay for procedure code 13121 rendered on January 27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 13121 is not supported. 
Based on the medical records and the documentation of undermining and closure by W plasty, there is a more 
specific code to report the services provided. This does not meet criteria to report a complex closure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 13121 rendered on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says further studies and research are needed to corroborate that geniculate artery 
embolization is as good or better than standard treatments for knee osteoarthritis. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is an experimental procedure that is the subject of ongoing clinical trials. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve geniculate artery embolization.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0428 and A0425 for date of service 
January 16, 2023. 
 
You asked the Plan to pay for procedure codes A0428 and A0425. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Review of the file shows that these services were billed with 
diagnosis codes R53.1 (Weakness) and M62.81 (Muscle weakness (generalized). Due to an Excludes1 note, 
these two diagnosis codes should not be billed together. The claim is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of procedure codes A0428 and A0425 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A0428 and A0425 for date 
of service January 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee's quality of life is impacted due to 
their psoriasis. You also say that the enrollee has failed on topicals and Otezla. 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 Skyrizi.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 for date of service September 16, 
2022. 
 
You asked the Plan to pay for procedure code 99222. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says 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 99222 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 moderate 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 moderate severity. Typically, 50 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 procedure code 99222. Our physician reviewer says that 
the documentation does not support the code billed. Our reviewer found the enrollee has a with history of 
prostate cancer, coronary artery disease, chronic kidney disease. The enrollee presented with shingles and 
elevated creatinine. The documentation does not support a comprehensive history. Therefore, code 99222 is not 
supported. 
 
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 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 for date of service September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on December 5, 2022. 
 
You asked the Plan to pay for wound care. You say that it is medically necessary. The Plan denied your 
request. The Plan says it 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 pay for wound care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it was not emergent, nor was there any contraindication to use an in-network provider for this 
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 wound care have not been met. Therefore, we decided that the Plan does not 
have to pay for wound care provided on December 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee requires a lung cancer 
screening being at high risk for lung cancer and would benefit from early detection. The Plan denied your 
request. The Plan says the enrollee is not within the age requirement for Medicare to cover the service. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is 78 years old, which is outside of the 
age range for these services. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 13, 2022, to 
June 22, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have billed the services at issue correctly. The Plan denied your request. The Plan says inpatient hospital care 
does not meet criteria for payment at the DRG originally billed. 
 
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 provided with secondary diagnosis code G93.41, defined as 
Metabolic encephalopathy. 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 reviewer says that the services at issue do not meet criteria 
for payment at the DRG originally billed. Our physician reviewer found that the enrollee presented to the 
hospital following a fall at home and was found to have hyponatremia and was admitted and treated for 
syndrome of inappropriate antidiuretic hormone release (SIADH). Following initial treatment in the emergency 
department ED on admission and during the hospital stay, although it was noted that the enrollee had 
confusion, this was not consistent throughout and documentation also stated that the enrollee was found to be 
alert and oriented without evidence of altered mental status. Therefore, code G93.41 is not sufficiently 
supported in the provided documentation for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 13, 2022, to June 22, 2022, at the DRG originally billed.
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 you the services are medically necessary for you to 
return to your prior level of function before going home. The Plan denied your request. The Plan says you do 
not meet the criteria for admission to a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
April 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee received infusions. 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. 
 
We find that the enrollee received outpatient intravenous insulin therapy, billed with CPT codes 96365 and 
96366. This service is considered non-covered by Medicare. There is also a more accurate code to describe the 
services provided. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 
96366 billed for date of service April 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on April 11, 
2023. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were not told this was 
considered outpatient surgery. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $225 copayment for the arthrocentesis. This item/service falls within the in-
network outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
arthrocentesis provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services. 
 
You asked the Plan to pay for acupuncture services. You say that it is medically necessary. The Plan denied 
your request. The Plan says you do not meet the Medicare criteria for coverage of acupuncture treatment. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 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 acupuncture services. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found provided medical records document a 
diagnosis of low back pain, unspecified, but the medical records do not clarify that the pain is chronic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acupuncture services have not been met. Therefore, we decided that the Plan 
does not have to pay for acupuncture services.