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

 
We decided that the Plan does not have to pre-approve a transforaminal lumbar interbody fusion procedure. 
 
You asked the Plan to pre-approve a transforaminal lumbar interbody fusion. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
services are 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 a transforaminal lumbar interbody 
fusion. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found no documented lumbar instability, fracture or lesion. Fusion surgery is 
not medically needed for lumbar degenerative disc disorder. 
 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 transforaminal lumbar interbody fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a transforaminal lumbar interbody fusion procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial with supporting medical 
records. The Plan denied your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have complex nursing or rehabilitation needs. 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 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 you need a higher level of care than you can get in a 
nursing facility.  The Plan denied your request. The Plan says your needs can be met at a lower level of care 
than 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
orthostatic hypotension. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging single photon emission 
computed tomography (SPECT) (78803). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 service. Our physician reviewer 
found there is no documentation that the SPECT scan at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. The provided medical records do not document a concern 
for a stress fracture, spondylosis, infection (e.g., discitis), tumor (e.g., osteoid osteoma), or a need to analyze 
blood flow to an organ, as in the case of myocardial viability or to differentiate ischemic heart disease from 
dilated cardiomyopathy, as required by the NCD 220.12. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging single photon emission computed tomography (SPECT) 
(78803).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99499) with a neurologist to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the last neurosurgeon advised that the 
symptoms the enrollee had were not related to surgery, but the provider recommends a nerve stimulation for 
the enrollee. The Plan denied your request. The Plan says the enrollee must use network providers to get 
medical care and services when network providers are available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99499) with a neurologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these supplies for bladder 
control issues. The Plan denied your request. The Plan says these supplies are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you want this item. The Plan denied your 
request. The Plan says knee scooters are considered convenience items, not primarily medical in nature, and not 
medically necessary.  
 
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 a knee scooter (E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (38700, 21025) provided on November 17, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (38700, 21025) is included in the 
global surgery payment for the procedure (15733) provided on September 22, 2022, which has a 90-day global 
period. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for the services (38700, 21025) provided on 
November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the pneumatic compression device (E0675). 
 
You asked the Plan to pay for  the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this item is not covered by Medicare to prevent deep 
vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  the pneumatic compression device (E0675).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomographic angiography (CTA) scan of blood 
vessels of abdomen and pelvis. 
 
You asked the Plan to pre-approve the CTA scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that they did not receive results of a recent ultrasound and they need the 
results before moving forward with the CTA scan.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CTA scan. Our reviewer says that 
the CTA is medically necessary. Our physician reviewer found while there has been apparent stability of the 
aorta on 2 prior CTA exams a recent ultrasound report showed a mid-abdominal aortic measurement of 1.8 x 
4.9 centimeters (CM). The 4.9 CM value may be artefactual due to technique but 4.9 CM diameter either in the 
transverse or anterior-posterior direction is worrisome for an abdominal aortic aneurysm. In addition, the iliac 
arteries were not well seen. For these reasons listed the requested CTA is 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 CTA scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomographic angiography (CTA) scan of blood vessels of abdomen and pelvis.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the attendant care services; per 15 minutes (S5125). 
 
You asked the Plan to pre-approve the attendant care services. You say that you feel that the enrollee needs 
more hours that 20 per week. The Plan denied your request. The Plan says Medicare does not cover custodial 
care or personal care attendant services. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the attendant care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the 
attendant care services; per 15 minutes (S5125).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 17312 billed for date of service December 5, 
2022.  
 
You asked the Plan to pay for procedure code 17312. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 17312 is 6. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 17312 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 17312 billed for date of service December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says at this time, enrollee does appear to be functioning significantly below 
baseline and while continued therapies would be beneficial, this can be provided at a lower level of care. 
According to the available records, the enrollee does not meet all the required Medicare criteria for admission 
to an Inpatient Rehabilitation Facility. Skilled therapies at home or at a skilled nursing facility 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) with a gynecologist to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are not happy with the Plan's providers. 
The Plan denied your request. The Plan says you must receive your care from a network provider. The services 
requested are for standard/routine care that can be provided by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99205) with a gynecologist to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the member does not need intensive team treatment or frequent physician 
evaluations, the member can receive physical therapy and occupational therapy in a less intensive setting, such 
as sub-acute rehabilitation, a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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. The Plan denied your request. The Plan says the medical records 
submitted do not establish that an IRF admission is reasonable and necessary. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer also found that there is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that a fully electric hospital bed will 
assist the enrollee with body rotation while in bed to avoid skin breakdown. The Plan denied your request. The 
Plan says total electric hospital beds are statutorily excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).