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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the rehabilitation services following hip 
replacement surgery and a recent fall. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
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 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection (62323). 
 
You asked the Plan to pre-approve the injection. You say that you have been receiving this shot for back pain 
since the beginning of the year without any incident. You need the shot as a part of pain management 
procedures. The Plan denied your request. The Plan says the requested epidural injection is considered not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found guidelines by the American Society of Interventional Pain Physician state that for epidural 
steroid injections, in the therapeutic phase, the suggested frequency would be 2 months or longer between injections, provided that greater than 50% relief is obtained for at least 6 weeks. There is no documentation in 
the provided records of the percentage or duration of pain relief or functional improvement with the enrollee's 
prior lumbar epidural steroid injections. The review has determined that the epidural steroid injection at issue in 
this case is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the epidural steroid injection (62323).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health/hospice services billed with codes G0299 
and Q5001 for January 18, 2021, to February 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the diagnosis codes were not billed with a required procedure code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health/hospice services billed with codes G0299 and Q5001 for January 18, 2021, to February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A6222, A6446, and A4450 for date of service 
December 14, 2022. 
 
You asked the Plan to pay for codes A6222, A6446, and A4450. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the items are not payable as 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 find that codes A6222, A6446, and A4450 are not supported in the medical record. Specifically, these 
codes were billed with place of service 12 (home). The documentation shows that the enrollee was registered as 
an inpatient of a hospital for this date of service. This means it is inappropriate to bill these items with a place 
of service 12. The claim is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of codes A6222, A6446, and A4450 have not been met. Therefore, we decided that the Plan does not 
have to pay for codes A6222, A6446, and A4450 for date of service December 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the cataract removal billed with code 66984 for November 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the claim was billed with the incorrect source code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the services were billed with the incorrect source code; 
however, there is no reference to binding Medicare rules to support this denial reason. An admission source 
code is required for an inpatient admission but that is not the service at issue. The Plan has not provided any 
documentation to support that the claim is not payable as billed. Therefore, we decided that the Plan has to pay 
for the cataract removal billed with code 66984 for November 17, 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: SNF
Decision: Favorable

 
We decided that the Plan has to hold the enrollee harmless for the transportation services received by the 
enrollee from August 26, 2022, to September 2, 2022. 
 
You asked the Plan to pay for the transportation services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that no transportation was provided. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was provided the services by a contract provider. The file does not show that the plan provided 
notice that the services would not be covered. Under Medicare rules, this means the services is considered 
approved by the plan. In addition, the documentation is conflicting regarding the services received. The 
services were billed by a skilled nursing facility; however, the Plan states that the services were for 
transportation. Without solid documentation regarding the appropriate services at issue, the Plan did not 
substantiate their denial. Therefore, we decided that the Plan has to hold the enrollee harmless for the 
transportation services received by the enrollee from August 26, 2022, to September 2, 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 pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that due to mitigating factors 
including tissue mobility, critical location of the lesion, deformity and/or unacceptable scarring it has been 
determined that the requested radiation therapy is the best option and is medically necessary for this enrollee. 
The Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. Policy states that US-IGRT is not medically necessary for superficial radiation therapy. There is not 
enough evidence that this type of radiation therapy guidance is needed or effective for the enrollee's skin 
cancer. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found although single reports published in the medical literature are 
encouraging, I agree with the previous reviewer that there is not enough evidence that this type of radiation 
therapy guidance is needed or effective for the type of skin cancer lesions in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary. Our physician 
reviewer found the enrollee had a 4-L5 epidural steroid injection on March 17, 2023, and the enrollee achieved 
60% pain relief. The physician requested a repeat ESI at that level before three months have passed. The 
Medicare LCD criteria requires three months of 50% pain relief, which was not achieved and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Stereotactic Radiation Therapy (SBRT) (77371). 
 
You asked the Plan to pre-approve SBRT. You say that you are requesting SRS to the brain. The enrollee has 
breast cancer with new metastasis to the brain. The SRS/Gamma Knife radiation requested is standard of care; 
FDA approved, follows NCCN and is not investigational. The Plan denied your request. The Plan says that the 
request does not meet the Medicare or health plan coverage criteria. There is no good evidence the SRS 
treatment is safe or effective or best for the enrollee's cancer. 
 
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 SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found stereotactic radiosurgery (SRS) is an accepted standard of care for limited brain metastases 
from breast cancer. The ASTRO model policy for radiosurgery and ASTRO Choosing Wisely statement 
consider SRS standard of care. The NCCN guidelines state (and have stated since at least 2014) that 
radiosurgery can be considered for enrollees with multiple brain metastases with low-volume burden of 
disease, and that SRS can be considered for enrollees with good performance status and low overall tumor 
volume. It is unclear to our reviewer what the basis for denial in this case is. As SRS is a standard of care 
option, with the alternative being a treatment with potential severe morbidity, the decision is favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
Stereotactic Radiation Therapy (SBRT) (77371).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
laparoscopic hernia repair without mesh and gastrointestinal endoscopy and will need inpatient admission after 
surgery. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a laparoscopic hernia repair without mesh and 
gastrointestinal endoscopy. The record does not document that the treating physician has a reasonable 
expectation of a length of stay spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 26-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
frequent doctor and laboratory visits. The Plan denied your request. The Plan says the requested number of 
trips exceeds your trip limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 26 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
26-trip limit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar kyphoplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) 
does not show an acute fracture that is less than six weeks old. The criteria for coverage are not met; therefore, 
the kyphoplasty is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001). 
 
You asked the Plan to pre-approve a standard wheelchair. You say that the wheelchair is medically necessary 
due to other general symptoms and signs. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for approval of the requested wheelchair. 
 
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 standard wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee complains of unsteady gait. She lives alone and has had no falls. The 
record states she could use a wheelchair or a cane. The evidence does not indicate the enrollee requires a 
wheelchair to complete her MRADLs. 
 
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 standard wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on October 11, 2022, billed with 
code 93922. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 
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 the testing services provided. 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 evidence of a diagnosis, signs or symptoms that warranted the performed 
testing. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on October 11, 2022, billed with code 93922.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the device is medically necessary due to chronic 
obstructive pulmonary disease. The Plan denied your request. The Plan says it is not reasonable and necessary 
for an enrollee to use both a high frequency chest wall oscillation devices device and a mechanical in-
exsufflation device. The enrollee does not meet criteria for approval. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found provided records in this case do not document 
a diagnosis of cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high frequency 
chest wall oscillation device may be covered. The enrollee presently uses incentive spirometry and a flutter 
valve, but records do not document use of a mechanical in-exsufflation device (E0482) and plans to continue to 
do so. Provided records in this case do not document well-documented failure of standard treatments to 
adequately mobilize retained secretions. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).