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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 17, 
2022, to September 19, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient admission have not 
been met. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.Our 
physician reviewer found due to the workup revealing low complexity, low severity clinical situation, the 
enrollee was not expected to require hospital care that would likely cross 2 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 pay for the acute inpatient hospital care provided September 17, 2022, to September 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0825) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that it was reported that a 
scooter would be too big for your house. The Plan denied your request. The Plan says that the notes submitted 
by your doctor do not document why you cannot use a power operated vehicle (scooter). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that you are not at 
high risk for skin breakdown, do not use a catheter, and do not have spasticity. You do not require alternative 
power controls. As the power wheelchair base is not medically necessary, the requested accessories are not 
covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 power wheelchair (K0825) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services (74240,74230, 72040, 70100, 70310) provided 
on February 8, 2023. 
 
You asked the Plan to pay for x-ray services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another Place of Service (POS) code exists. For example, a 
mobile unit may be sent to a physicians office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity.  
 
We looked at the file and Medicare rules. The services at issue were provided in a mobile unit servicing a 
nursing facility but were billed with an office POS. Based on this information, we decided that Medicare rules 
for coverage of x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for 
x-ray services (74240,74230, 72040, 70100, 70310) provided on February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and consultations (88321, 88323, 99205, 
99215, 99245) with an oncologist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and consultations. You say that you disagree with the denial 
and request reconsideration. You need to be seen at this facility. The Plan denied your request. The Plan says 
the records received do not indicate that you have an emergent or urgent medical condition or need specialized 
service(s) that are not available in the network. You have an HMO (Health Maintenance Organization) plan. 
There are in-network provider(s) within a reasonable distance from your location that can provide this service 
or item. You have already been approved to see 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 
office visits and consultations (88321, 88323, 99205, 99215, 99245) with an oncologist 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 a Genium X3 microprocessor-controlled knee.  
 
You asked the Plan to pre-approve the Genium X3 prosthetic knee. You say that this item is necesary as the 
enrollee wishes to have a prosthetic that can be used in the water.  The Plan denied your request. The Plan says 
the Genium X3 is a deluxe item that is requested for convenience purposes. There are standard prosthetic knees 
that are able to be used in water which can be approved if requested. 
 
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 Genium X3 prosthetic knee. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found typical microprocessor knees (MPKs), as routinely described by L5856 and/or other 
related codes) are largely covered by Medicare for level 3 or 4 ambulators because of their long-established 
superior function and safety in normal home and community settings for essential mobility and activity of daily 
living (ADL) performance. L5999, as used here by the prosthetist to describe the Genium X3, appears to be 
intended to describe complete waterproofing (salt and fresh water), because it is functionally the only feature 
that really distinguishes this knee from the C-leg and other comparable MPKs. The Genium X3s use for this 
enrollee appears to be a matter of convenience.  
 
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 Genium X3 prosthetic knee have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Genium X3 microprocessor-controlled knee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine (72148). 
 
You asked the Plan to pre-approve an MRI. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found that the enrollee has severe low back pain and 
radicular symptoms. The enrollee has been on a course of methylprednisolone, which is an oral steroid. Per the 
Plan's guidelines if an enrollee is taking steroids, even by mouth, they qualify for an MRI as a medical 
necessity. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI of the lumbar spine (72148).  
 
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for sepsis and urinary tract infection. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does 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. There is not a reasonable expectation that this 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the genicular nerve radiofrequency ablation. The Plan denied your request. 
The Plan says a genicular nerve radiofrequency ablation is 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
the enrollee is not enrolled in a clinical trial, although the use of a radio frequency ablation of the genicular 
nerves post total knee replacement is the subject of ongoing clinical trials. Therefore, the request is not 
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 the radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urology services provided on October 6, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for urology services. You say that the hospital should have obtained authorization, 
The Plan denied your request. The Plan says this was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for urology services provided on October 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Intracept procedure. 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 magnetic Resonance Imaging (MRI) showing only modic changes without 
facet degenerative joint disease (djd) or foraminal stenosis. The cause of the back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88366 billed for date of service February 27, 
2023.  
 
You asked the Plan to pay for procedure code 88366. You say that these services were necessary and are 
supported in the medical record. 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 88366 is 2. The MAI value for this code is 3. You billed 4 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 88366 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88366 billed for date of service February 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37233, 36140, 99152, 99153, and J3010 
billed for date of service October 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services. 
 
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 the CPT codes at issue are not supported in the medical record. Specifically, the records do not 
show that revascularization fourth vessel (37233) was performed. The records do not include the presence of an 
independent trained observer (99152 and 99153). The records do not indicate fentanyl citrate was provided. 
The records do not show that code 36140 was a service that does not usually overlap code 37229. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 37233, 36140, 99152, 99153, and J3010 
billed for date of service October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of a skin substitute graft (15275 x 10) 
and Kerecis Omega 3 (Q4158 x 10). 
 
You asked the Plan to pre-approve the application of a skin graft and Kerecis Omega 3. You say that you need 
the wounds to heal quick for surgery. The Plan denied your request. The Plan says these 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 the application of a skin graft and 
Kerecis Omega 3. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the wounds should heal prior to considering other 
options. 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 application of a skin graft and Kerecis Omega 3 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the application of a skin substitute graft 
(15275 x 10) and Kerecis Omega 3 (Q4158 x 10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 98941 billed for date of service January 6, 
2023, to February 3, 2023.  
 You asked the Plan to pay for procedure code 98941. You say that you believe you have fixed your billing. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 98941 is 1. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 98941 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 98941 billed for date of service January 6, 2023, to February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation (93461). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says cardiac catheterization is only necessary if the enrollee has high risk 
findings on a stress test or are scheduled to undergo high risk surgery. The enrollee has not had high risk 
findings on a stress test and is not scheduled for high-risk surgery. The enrollee does not meet criteria for 
approval. 
 
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 left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has exhibited dyspnea on exertion for the past 3 years. The 
enrollee has had no chest pain. An echocardiogram in March 2023, showed a normal ejection fraction. The 
medical records provided do not support the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would 
not be considered medically appropriate and necessary in this enrollee's clinical management. 
 
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 left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation 
(93461).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.