Persius/hicric huggingface dataset:
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 a fall risk and are afraid to return home. The 
Plan denied your request. The Plan says you do not meet the requirements for a SNF admission. 
 
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 require daily skilled nursing or therapy services. You do not meet the 
severity of illness or intensity of service criteria for an inpatient basis in an SNF. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The 
appellant says the LTACH will vastly improve the enrollee's opportunity and potential to return to baseline 
status while minimizing the enrollee's risk of failing at a lower level of care.  The Plan denied your request. The 
Plan says the LTACH services are not medically necessary, and the enrollee's needs are being met in the 
current hospital location. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with a spinal abscess and later suffering a cardiac arrest. The enrollee was intubated/ 
ventilated, and subsequently received a tracheotomy and feeding tube. The enrollee is tolerating weaning trials, 
but his long-term functional prognosis is unclear. There is no evidence that the enrollee requires services that 
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long-term care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupogen. 
 You asked the Plan to pre-approve Neupogen. 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. 
 
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 Neupogen. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neupogen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neupogen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections.  
 
You asked the Plan to pre-approve repeat epidural steroid injections. You say that the first injection helped the 
enrollee with their pain and a general increase in their function and they would like another one. The Plan 
denied your request. The Plan says this does not meet the LCD criteria for coverage. 
 
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 repeat epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the LCD requires 50% 
pain improvement for 3 months. This was not achieved and adding dorsal root ganglion RFA does not qualify 
as a change in approach of the epidural steroid injection. The request is deemed as 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 repeat epidural steroid injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you were in the hospital and 
discharged with oxygen, so you need this approved. The Plan denied your request. The Plan says the request 
does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable oxygen concentrator. Our 
reviewer says that a portable oxygen concentrator is not medically necessary. Our physician reviewer found 
that the medical records indicate that you were admitted to the hospital on January 28, 2023, following a motor 
vehicle collision resulting in a fractured radius. The oxygen saturation by pulse oximetry was 98% breathing 
room air on admission. There is a note indicating that you were to be discharged home on January 30 on 
oxygen at 2 Liters/minute.  However, there is no information in the record indicating why the oxygen was 
needed. There is no pulmonary diagnosis. There are no pulse oximetry measurements or arterial blood gases 
documenting hypoxemia. There are no medical visits subsequent to January 2023. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
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 July 5, 2023. 
 
You asked the Plan to pay for procedure code 99053. You say that 99053 should be paid as billed because it is 
supported in the medical record. 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 July 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CoFlex device (22867). 
 
You asked the Plan to pre-approve a CoFlex device. You say that this service is medically necessary. The Plan 
denied your request. The Plan says there is a consensus that further study is necessary for the CoFlex device. 
 
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 CoFlex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the CoFlex device is experimental in spine 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 CoFlex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the CoFlex device (22867).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 14060, 17311, and 17312 rendered on 
March 8, 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 14060: 
 
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less 

CPT 17311: 
 
Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, 
mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and 
histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, 
hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major 
nerves, or vessels; first stage, up to 5 tissue blocks 
 
CPT 17312: 
 
Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, 
mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and 
histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, 
hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major 
nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to 
code for primary procedure) 
 
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 in terms of CPT 14060, the 
procedure report describes extensive undermining to create flap, which was pulled over defect. In this case, 
adjacent tissue transfer is not supported. 
 
In terms of CPT 17311 and CPT 17312, the provider reported a diagnosis of C44.99 - other specified malignant 
neoplasm of skin, unspecified, to support the Mohs procedure. Services should be coded to highest level of 
specificity. This diagnosis code is not approved for the Mohs procedure. 
 
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 codes 14060, 17311, and 17312 rendered on March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61783 provided on March 24, 2023. 
 
You asked the Plan to pay for procedure code 61783. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for procedure code 61783 provided on 
March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement wheelchair cushions (E2620, E2607, 
K0108). 
 
You asked the Plan to pre-approve replacement wheelchair cushions. You say that the items are necessary. The 
Plan denied your request. The Plan says the requested items are still under warranty. 
 
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 replacement wheelchair cushions (E2620, E2607, K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an inpatient hospital stay, laboratory 
services, and a CT scan provided from April 21, 2023, to June 8, 2023. 
 
You asked the Plan to waive the cost share for an inpatient hospital stay, laboratory services, and a CT scan. 
You say that you disagree with the cost share applied. 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 $245 
copayment per day for days 1 to 7 and $0 copayment for additional days for inpatient hospital care, 35% 
coinsurance for each out-of-network (OON) CT scan and a $20 copayment for each laboratory service 
performed by a provider other than your primary care physician.  
 
You have been asked to pay a $411.23 for an inpatient hospital stay, lab services, and a CT scan.  
 
The inpatient hospital stay falls within the inpatient hospital care benefit category. The lab services and CT 
scan fall within the outpatient diagnostic tests 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 cost share 
for an inpatient hospital stay, laboratory services, and a CT scan provided from April 21, 2023, to June 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unspecified wheelchair accessory (K0108) and a cane/crutch holder (E2207).

You asked the Plan to pre-approve an unspecified wheelchair accessory and a cane/crutch holder. You say that the items are necessary. The Plan denied your request. The Plan says there is no a standard written order for these accessories. Additionally, a cane/crutch holder is not primarily medical in nature.

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 pre-approve an unspecified wheelchair accessory (K0108) and a cane/crutch holder (E2207).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on May 31, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you were in severe pain and sought 
chiropractic care assuming your copayment would cover everything. The Plan denied your request. The Plan 
says this chiropractic service is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630) provided on June 5, 2023, and June 22, 2023. 
 
You asked the Plan to pay for the drugs or medicaments. The Plan denied your request. The Plan says this 
service is not a covered expense under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for drugs or 
medicaments dispensed in the office for home use (D9630) provided on June 5, 2023, and June 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5 vertebroplasty (22511). 
 
You asked the Plan to pre-approve L5 vertebroplasty. 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 follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary 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 L5 vertebroplasty. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documented trial of 
bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5 vertebroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve L5 vertebroplasty (22511).