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

 
We decided that the Plan does not have to pre-approve the single photon emission computed tomography 
(SPECT) (78830). 
 
You asked the Plan to pre-approve the nuclear medicine test. You say that you are appealing the denial for a 
DAT scan to check for Parkinson's disease. The enrollee cannot have MRI due to spinal stimulator. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the nuclear medicine test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the enrollee is not noted to have an indication/diagnosis for which the 
NCD readily supports the provision of the requested service. The evaluation of Parkinsons Disease is not one 
for which this service is supported for use in the NCD. In as much it cannot be said to meet Medicare criteria 
for coverage 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 nuclear medicine test have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the single photon emission computed tomography (SPECT) (78830).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a stero-tactic body radiation therapy. 
 
You asked the Plan to pre-approve a stero-tactic body radiation therapy. You say that it is medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules state that radiation therapy may be covered if certain 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 stero-tactic body radiation therapy. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the treatment is within 
accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stero-tactic body radiation therapy have been met. Therefore, we decided that 
the Plan has to pre-approve a stero-tactic body radiation therapy.  
 
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 pay for the inpatient hospital services provided on June 14, 2021, to 
June 15, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the documentation did not clinically validate the diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with J96.01, defined as acute respiratory failure with hypoxia. 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 inpatient hospital services at the DRG 
originally billed. Our physician reviewer found that the enrollee presented to the hospital with increased 
dyspnea. The enrollee was not in any acute respiratory distress and was alert and oriented. He was given 
oxygen with benefit. Imaging showed atelectasis but no infection. He was able to be weaned to room air shortly 
afterward. The enrollee never required high flow oxygen support, BiPAP, or vent support and was never in 
acute respiratory distress. Therefore, the code at issue, J96.01, was not sufficiently supported.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on June 14, 2021, to June 15, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve enhanced external counter pulsation (EECP) therapy at the in-
network rate when provided by an out-of-network provider. 
 
You asked the Plan to pre-approve EECP at the in-network rate. You say that the enrollee was referred to this 
provider as they are the only provider of EECP within at 50-mile radius. You also say that none of the Plan 
providers that were offered perform EECP. The Plan denied your request. The Plan says that this is available 
by a provider in-network. The Plan also says that services received out-of-network may have a higher cost 
share. 
 
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 did not indicate if there were in-network provider's that could provide 
the service in this case. The Plan also did not support that this service was not medically necessary. Therefore, 
we decided that the Plan has to pre-approve enhanced external counter pulsation (EECP) therapy at the in-
network rate when provided by an out-of-network provider.  
 
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 rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
an Inpatient Rehabilitation Facility. Services needed may be provided safely in a lower level of 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 pay for the ultrasonic guidance for needle placement (76942). 
 
You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the service was 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 pay for the ultrasonic guidance for needle 
placement. Our reviewer says that the requested service was not considered medically reasonable and necessary 
in this case. Our physician reviewer found ultrasound guidance for wrist injections is not standard of care as palpation of the tendons and joint spaces are typically sufficient to accurately place a needle. There was no 
unique anatomy noted to consider this an exceptional case for this. 
 
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 ultrasonic guidance for needle placement have not been met. Therefore, we 
decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 a VASS. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found any experienced clinician in this space knows that VASS is very much in the mainstream of 
standards of prosthetic care. Though Medicare policy is technically non-specific about coverage rules for 
VASS, it does in fact routinely cover it, meaning it cannot be on its face experimental.  For this enrollee and 
many like him, this technology materially complies with the general reasonable and necessary criteria laid out 
in Ch 13 of the Program Integrity Manual. 
 
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 VASS have been met. Therefore, we decided that the Plan has to pre-approve 
a vacuum assisted socket system (VASS) (L5781).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Inpatient hospital care provided on January 5, 2022, billed 
with evaluation and management (EM) code 99223. 
 
You asked the Plan to pay for the Inpatient hospital care provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our physician 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 Inpatient hospital care provided. Our reviewer says 
that the documentation does not support the billed code. Our reviewer found that this initial hospital care 
evaluation and management code requires a comprehensive history, a comprehensive examination and medical 
decision making of high complexity. In this case, the medical records submitted did not support a 
comprehensive history. 
 
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 Inpatient hospital care provided have not been met. Therefore, we decided 
that the Plan does not have to pay for Inpatient hospital care provided on January 5, 2022, billed with 
evaluation and management (EM) code 99223.
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 the enrollee needs inpatient rehabilitation facility 
admission.  The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 
fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can 
be met 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical collar (L0180) provided on February 6, 2023. 
 
You asked the Plan to pay for a cervical collar. You say that the item at issue was not a duplicate claim. The 
Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for a cervical collar received by the enrollee on September 16, 2022. Therefore, the requested replacement is for an item that has 
not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for 
coverage of a cervical collar have not been met. Therefore, we decided that the Plan does not have to pay for a 
cervical collar (L0180) provided on February 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance mileage (A0425) billed for date of service 
October 5, 2022. 
 
You asked the Plan to pay for ambulance mileage. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says this code was reported with a number of units which 
exceeds the number of units which may be reported on a single line for this service. 
 The Plan must follow Medicare rules. Medicare rules say that claim lines submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 1. If a code has an MAI of 1, appropriate use of 
a modifier may be used to report the same code on separate lines of the claim, and each line for that code will 
be separately evaluated against the MUE value for that code. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 701 units of 
this code on a single line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance mileage (A0425) billed for date of service October 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 the enrollee will benefit deeply from continued 
rehabilitation especially since it is a medical necessity with her conditions.  The Plan denied your request. The 
Plan says based on Medicare guidelines, the IRF services requested 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 
fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can 
be met 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: 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 meets the full criteria for an inpatient 
acute rehab stay, which is needed for rehabilitation to maximize potential to return to previous level of 
independence. The Plan denied your request. The Plan says the enrollee's records do not show you need an 
intensive team (rehab doctor and nurse, social worker, and therapists) for care. Services needed may be 
provided safely in a lower level of 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 genicular nerve blocks. 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that you feel as though this procedure will 
provide the patient with temporary, if not permanent, pain relief, which will help with activities of daily living. 
The Plan denied your request. The Plan says genicular nerve blocks are not the standard of care for the patient's 
condition. Current medical literature does not consider this service to be the standard of care. 
 
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 genicular nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 68 year old female with a history of bilateral knee pain due to 
osteoarthritis.  The enrollee has been treated with medication and heat with improvement in symptoms. An x-ray of the left knee demonstrated an intact joint space and a quadriceps enthesophyte.  You have requested 
genicular nerve blocks. Genicular nerve blocks and genicular nerve ablation are considered investigational and 
not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks.