Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay for inpatient behavioral health, from 
December 5, 2023, forward. 
 
You asked the Plan to pre-approve a continued stay for inpatient behavioral health. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says this is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued stay for inpatient 
behavioral health. Our reviewer says that the requested continued stay for inpatient behavioral health is not 
medically necessary. Our physician reviewer found his enrollee did not appear to require inpatient mental 
health treatment beyond the date in question as she was not a danger to herself or others and does not have 
auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in 
question. It did not appear that the services were reasonably expected to improve the patients condition or for 
the purpose of diagnosis beyond the date in question. Therefore, the reviewer found that the requested 
continued stay 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 continued stay for inpatient behavioral health have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continued stay for inpatient behavioral health, from 
December 5, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 23, 
2023. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (vedolizumab). 
 
You asked the Plan to pre-approve Entyvio. You say that the enrollee's condition is currently poorly controlled. 
The Plan denied your request. The Plan says this drug is not being requested for a medically-accepted 
indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Entyvio. Our reviewer says that 
Entyvio is not FDA approved. Our physician reviewer found medical records provided does not support the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested dose. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (vedolizumab).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has failed conservative treatment and 
you would like an updated MRI given symptom changes. The Plan denied your request. The Plan says that the 
request for an MRI is not medically necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
request is medically necessary. Our physician reviewer found that the record indicates that the enrollee has low 
back pain with worsening radiculopathy. The enrollee has failed conservative therapy including injection, has 
abnormal neurological examination findings, and that the provider is using the requested test to determine 
appropriate next interventions, including possibly surgery. The requested service is medically necessary and 
reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI of the lumbar spine.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied CGM and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS device. You say that this is safe and effective for the enrollee. 
The Plan denied your request. The Plan says this 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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer 
found that the requested CardioMEMS device 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of CardioMEMS device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet injection. 
 
You asked the Plan to pre-approve facet injection. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that they did not receive any information that would 
allow them to select the specific guideline criteria needed for review that apply to the enrollee's condition. 
 
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 facet injection. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the request meets all of the local coverage determination (LCD) criteria and is 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 facet injection have been met. Therefore, we decided that the Plan has to pre-
approve facet injection.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring device (K1024, K1033). 
 
You asked the Plan to pre-approve the Koya Dayspring device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this device 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 Koya Dayspring device. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device 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 Koya Dayspring device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Koya Dayspring device (K1024, K1033).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric (SE) hospital bed.  
 
You asked the Plan to pre-approve the SE hospital bed. You say that medical records have been provided, and 
the requested bed should be approved. The Plan denied your request. The Plan says the submitted 
documentation does not objectively support medical necessity coverage for the requested hospital bed, or that the enrollee requires frequent changes in body position and/or that they have an immediate need for a change in 
body position. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 SE hospital bed. Our reviewer says 
that the requested SE hospital bed does not meet criteria for medical necessity. Our physician reviewer found 
the enrollee is a 76-year-old male with a diagnosis of malignant neoplasm of cortex of unspecified adrenal 
gland and cardiac failure who has been receiving services from hospice including a hospital bed. The enrollee 
has been discharged from hospice services and is requesting to keep the semi-electric hospital bed.  
 
In this case, the documentation doesnt support that the enrollee has a condition that requires frequent 
positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or 
avoid respiratory infections in a way that an ordinary bed is not able to. 
 
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 SE hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a semi-electric (SE) hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on July 27, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
eligible to bill Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the mental health services provided on 
July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug testing. 
 
You asked the Plan to pre-approve drug testing. You say that this testing is a crucial part of the enrollee's pain 
management regimen. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that drug testing may be covered for certain indications. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve drug testing. Our reviewer says that the 
enrollee does not meet criteria for this testing. Our physician reviewer found the documentation does not 
support that extensive drug testing is 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve drug testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services to regain strength 
and recover their previous quality of life. The Plan denied your request. The Plan says the enrollee does 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 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 services 
required can be provided in a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's ongoing rehabilitative needs warrant 
IRF level of care, and they meet IRF admission criteria. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval of the requested IRF services.  
 
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 services 
required can be provided in a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept device. 
 
You asked the Plan to pre-approve an Intracept device. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 an Intracept device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or stenosis. The cause of pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept device.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88341 billed for date of service September 22, 2022. 
 
You asked the Plan to pay for the billed service. You say that the medical records support the frequency of 
services. The Plan denied your request. The Plan says that no records support the services billed. 
 
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. 
 
We find that code 88341 is an add-on code that was billed with code 88342 which was paid for by the Plan. 
The Plan states that medical records were available, but that those records do not support the billed code at 
issue. The Plan did not provide these records, even after request. Without these records, we are unable to 
confirm or deny whether the medical records support the billed code at issue. The Plan has not made reasonable 
and diligent efforts to gather and forward to us information regarding their decision to deny your request. 
Therefore, we decided that the Plan has to pay for procedure code 88341 billed for date of service September 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service May 12, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting.  
 
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 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. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service May 12, 2023, billed with 
code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revita skin substitute. 
 
You asked the Plan to pre-approve Revita. You say that the skin substitute will aid in avoiding osteonecrosis. 
The Plan denied your request. The Plan says that the request does not meet medical necessity criteria. 
 
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 Revita. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on the medical records provided there is no documentation that the Revita skin 
substitute at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and 
effective for the patient. Provided records in this case do not document the presence of a burn wound or 
chronic, non-healing wound or other complex wound to meet criteria for the requested treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Revita have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Revita skin substitute.