Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
the requested items 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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee's upper extremity strength and 
functional ability, as shown by independence in feeding and hygiene, support that the enrollee can control any 
power options through their own switches. 
 
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 expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid service package (99499) 
purchased on March 8, 2023.  
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the service at issue in this case is not a covered 
benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aid service 
package (99499) purchased on March 8, 2023.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 6 additional PT visits. We decided that the Plan does not have to 
pre-approve the remaining 3 PT visits.  
 
You asked the Plan to pre-approve 9 additional physical therapy (PT) visits. You say that the 9 additional PT 
visits are necessary for the enrollee. The Plan says that the enrollee does not meet the criteria for the requested 
additional PT visits. 
 
We decided that the Plan has to pre-approve 6 additional PT visits and does not have to pre-approve the 
remaining 3 visits.  
 
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 item/service at issue. Our reviewer 
says that 6 additional visits are medically necessary. Our physician reviewer found that the enrollee has been 
making progress in terms of the active and passive range of motion of their right shoulder as well as function 
with daily activities. The enrollee's motor strength is nearly normal, and they would benefit from 6 additional 
PT visits to maximize range of motion and transition to a home exercise program. Therefore, we decided that 
the Plan has to pre-approve 6 additional PT visits and the remaining 3 visits are denied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional PT visit have been met. Therefore, we decided that the Plan has to 
pre-approve 6 additional PT visits and does not have to pre-approve the remaining 3 visits. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an i-FACTOR Peptide Enhanced Bone Graft 
(Cerapedics) (20930).  

You asked the Plan to pre-approve an i-FACTOR Peptide Enhanced Bone Graft. You say that this is medically 
necessary. The Plan denied your request. The Plan says Plan medical policy and guidelines consider these 
ceramic-based fusion enhancement products unproven and 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 an i-FACTOR Peptide Enhanced Bone 
Graft. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-
reviewed literature that shows this requested allograft to be an effective and/or safe treatment for the noted 
pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with 
conventional treatment. There is no compelling rationale presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
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 i-FACTOR Peptide Enhanced Bone Graft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an i-FACTOR Peptide Enhanced Bone Graft (Cerapedics) 
(20930).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 30, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 30, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were 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 inpatient psychiatric care from October 
30, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 30, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 30, 2023, as he 
was not a danger to himself or others and did not have any delusions, 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 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 30, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 30, 
2023, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 provided on December 30, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 5 units of CPT code 87481 are not supported in the medical record. The medical record only 
supports 4 units of CPT code 87481. Based on this information, we decided that Medicare rules for coverage of procedure code 87481 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87481 provided on December 30, 2022.
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 enrollee has been referred to Long 
Term Acute Care for complex medical management with an interdisciplinary treatment team approach. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer 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 the enrollee was admitted with a stroke and has had a complicated hospital course. 
The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services. 
Our reviewer found that the enrollee continues to receive acute care services, and these have not been denied. 
Our physician reviewer also found that the medical record does not indicate that the enrollee requires services 
that they are not currently receiving but that would be available at the LTACH facility. 
 
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: 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 requires therapy services as well as 
medical oversight that cannot be met in a lower level of care. The Plan denied your request. The Plan says the 
enrollee's records do not show that they have a need for an intensive team for their care.  
 
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 enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain their functional status. The 
enrollee can receive further services at 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics, Q-Logic joystick controller, flat 
hand pad, and calf panel. 
 You asked the Plan to pre-approve the accessories. You say that the enrollee's current power wheelchair needs 
to be replaced. You also say that the enrollee has been approved in the past for a Group 3 power wheelchair 
with power tilt, recline and power legs. The Plan denied your request. The Plan says the enrollee's upper limb 
function is therefore sufficient to control power options with the switches included with them. The Plan also 
says that the Q-Logic joystick controller, flat hand pad, and calf panel do not serve a medical purpose. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare rules say that items and services that are not 
medically necessary are not covered. Items/services that do not serve a primarily medical purpose are not 
covered either. 
 
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 accessories. Our reviewer says that 
the requested upgraded electronics are not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee's upper extremity strength and functional ability support that the enrollee 
can control any power options through their own switches. Therefore, the reviewer found that the requested 
upgraded electronics are 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 accessories have not been met. Specifically, the requested upgraded 
electronics are not medically necessary, and the Q-Logic joystick controller, flat hand pad, and calf panel do 
not serve a medical purpose. These items are 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 upgraded 
electronics, Q-Logic joystick controller, flat hand pad, and calf panel.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 31645 and 32200 rendered on April 5, 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 31645: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration 
of tracheobronchial tree, initial  
CPT 32200: 
 
Pneumonostomy, with open drainage of abscess or cyst 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 31645 is not supported. The 
operative report does not describe a bronchoscopy with therapeutic aspiration. CPT 32200 is not supported. 
The record does not describe the creation of an opening (ostomy) in the lung with open drainage of an abscess 
or cyst. There is a more specific code for the procedure described in the operating report. 
 
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 31645 and 32200 rendered on April 5, 2023.
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 to be monitored because your whole left 
side of your body is numb. You say that you have been diagnosed with cancer. The Plan denied your request. 
The Plan says an IRF admission 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 you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You can receive further services at 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. You asked the Plan to pre-approve Hymovis. 
You say that you do not carry or stock Orthovisc, Monovisc, Synvisc or Synvisc One in your office. The Plan 
denied your request. The Plan says standard hyaluronate policy does not allow coverage of the requested medication unless one of the following conditions is met: a) the enrollee has received the requested medication 
in the past 365 days, or b) the enrollee has had a bad side effect with Orthovisc, Monovisc and Synvisc or 
Synvisc One.  
 
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 Hymovis. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the documentation provided does 
not corroborate the trial and failure of the required drug(s). The Plans required drug(s) would not 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 Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49591 rendered on July 10, 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 Current Procedural Terminology (CPT 49591) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 49491 is "Repair of anterior abdominal hernia(s) (ie, 
epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, 
including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, 
reducible." 
 
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 49591 is not supported. The 
operative report does not describe repair of a reducible hernia. The record states there was evidence of a 
previous hernia, but one was not documented at the time of the 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 code 49591 rendered on July 10, 2023.
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 enrollee now requires an LTACH 
level of care in order to successfully recover. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and is currently unstable for transfer 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 the enrollee was admitted with mycotic aortic aneurysm and required operative 
intervention. The record indicates that the enrollee has ongoing acute medical issues and still requires acute 
care services. Our reviewer found that the enrollee continues to receive acute care services, and these have not 
been denied. Our physician reviewer also found that the medical record does not indicate that the enrollee 
requires services that they are not currently receiving but that would be available at the LTACH facility. 
 
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.