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

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion. 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 sacroiliac joint fusion. 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 sacroiliac joint instability, fracture, or lesion. Sacroiliac joint fusion for 
degenerative back pain is experimental. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4 kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is only covered under certain 
conditions. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for the requested kyphoplasty. Our physician reviewer found there is no 
documentation of a trial of fracture bracing. More conservative measures are needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L4 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-care/home management training provided on December 
08, 2022, to December 30, 2022. 
 
You asked the Plan to pay for self-care/home management training. You say that the services should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for self-care/home 
management training provided on December 08, 2022, to December 30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on November 20, 2022. 
 
You asked the Plan to pay for procedure code 99285. 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 covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported. 
 
We looked at the file and Medicare rules. The E/M service in question was provided on the same day as E/M 
service (99285-25) provided by the same provider. This means that only one E/M service is payable. As code 99285-25 has already been processed and paid by the Plan, code 99285 is not payable in this case. Therefore, 
we decided that the Plan does not have to pay for procedure code 99285 provided on November 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 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 12 one-way transportation trips when each one-way trip does not exceed 30 miles. 
 
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 routine transportation mileage.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on January 3, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 10, 2023, billed with 
diagnosis codes M54.12 and M79.2. 
 
You asked the Plan to pay for the office visit as billed. You say that this was billed correctly and should be 
paid. The Plan denied your request. The Plan says this claim was billed with two diagnoses that should not be 
reported together.  
 The Plan must follow Medicare rules. Medicare rules say that ICD-10-CM guidelines indicate that some 
diagnosis codes have Excludes1 notes which indicate diagnoses with which they cannot be reported.  
 
We looked at the file and Medicare rules. Diagnosis code M54.12 has an Excludes1 note for M79.2, meaning 
that the two cannot be billed together. There is no evidence in the file that the two conditions are unrelated to 
one another. Based on this information, we decided that Medicare rules for coverage of the office visit as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on 
January 10, 2023, billed with diagnosis codes M54.12 and M79.2.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 has no complex or intensive rehabilitation needs. The enrollee cannot 
participate in or benefit from intensive rehabilitation pending full weight bearing status. No complex needs as 
the enrollee is chronically functionally impaired and now is simply more deconditioned and impaired with non-
weight bearing status.  
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary because you are in pain 
and need to get stronger. You also say and you are non-weight bearing and you have steps in your home. The 
Plan denied your request. The Plan says 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a serious, life-threatening 
constellation of acute medical problems that have left them at a functional status below their baseline. You also 
say the enrollee requires close daily oversight of care by a physician in an IRF setting. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While enrollee may have a need for physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR) 
(C1764). 
 You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical appropriateness and necessity of replacing the enrollees old ILR with a new ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR) (C1764).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Single-Photon Emission Computerized Tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. You say that you want the Plan to approve this. The Plan 
denied your request. The Plan says you do not meet 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 a SPECT scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records in this case do not document concern for a stress fracture, spondylosis, infection 
(e.g., discitis), tumor (e.g., osteoid osteoma), the need to analyze blood flow to an organ, as in the case of 
myocardial viability or to differentiate ischemic heart disease from dilated cardiomyopathy. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Single-Photon Emission Computerized Tomography (SPECT) scan (78803).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laboratory services provided on January 
17, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit and laboratory services. You say that this should be covered. 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 an office visit and laboratory services provided on 
January 17, 2023, 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 percutaneous implantation of neurostimulator 
electrode array (64555) and implantable neurostimulator (L8679). 
 
  You asked the Plan to pre-approve a percutaneous implantation of neurostimulator electrode array and 
implantable neurostimulator. You say that it was determined by the provider that the enrollee would be an 
excellent candidate for the percutaneous electrical nerve stimulation (PENS) unit to help with chronic pain and 
reduce the use of narcotics. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that acupuncture for stimulation of auricular points is not 
covered. Additionally, the rules say that acupuncture is only covered by Medicare for chronic low back pain. 
 
We looked at the file and Medicare rules. The requested acupuncture device is not being requested for chronic 
low back pain. Additionally, the device is for stimulation of the auricular points, which is not covered. Based 
on this information, we decided that Medicare rules for coverage of a percutaneous implantation of 
neurostimulator electrode array and implantable neurostimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array (64555) 
and implantable neurostimulator (L8679).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (WCE.) 
 
You asked the Plan to pre-approve . You say that the records provided support the need for the requested 
service.  The Plan denied your request. The Plan says the records do not show that the criteria for coverage 
have been met.  
 
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy (WCE) is covered when 
an EGD and colonoscopy have not identified suspected GI bleeding sites 
 
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. Our reviewer says that the criteria for 
coverage have not been met.  Our physician reviewer found the findings from the provided 
esophagogastroduodenoscopy (EGD) report showed gastric erosions with stigmata of recent bleeding, and 
esophageal mucocal changes that raised suspicion of short segment Barrett's esophagus. In addition, several 
antral polyps, also with stigmata of recent bleeding, were removed. A colonoscopy was also performed on the 
same day, and a number of polyps (8-15 millimeters in size) were resected. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pre-
approve a wireless capsule endoscopy (WCE.)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental. 
 
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 genicular nerve block. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested genicular nerve block is considered experimental for the treatment of 
chronic knee pain. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan.  The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan 
to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit 
provided on September 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS) (0398T). 
 
You asked the Plan to pre-approve MRgFUS. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that MRgFUS is covered when specific criteria is 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 MRgFUS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there was insufficient evidence to show 
LCD criteria was met. The records did not show evidence that the left hand was her dominant hand or that she had failed medication or deep brain stimulation or has a contraindication to such treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRgFUS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance image guided high intensity focused ultrasound (MRgFUS) (0398T).