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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not need 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, nor an intensive rehabilitation therapy program. While the medical record supports a need for skilled 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a lower 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 wound care supplies. 
 
You asked the Plan to pre-approve wound care supplies. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements 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 wound care supplies. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not show that the wound has failed to reduce in size by 50% after 
standard wound care. The provider has reported that the wound has been improving. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wound care supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve wound care supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the request is not medically 
necessary because there is little evidence in the medical literature to suggest that this is an appropriate 
procedure for the enrollee's back pain 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes 
without facet degenerative disc disease or stenosis. The cause of 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 further medical treatment. The Plan denied 
your request. The Plan says you do not meet Medicare guidelines for services in an inpatient rehabilitation 
facility. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall complies with the various documentation requirements for an IRF admission, 
as best summarized by the physician from October 16, 2023. Your condition is sufficiently complex, and there 
is every reason to expect that you will participate in and benefit from services to include physical and 
occupational therapy for adaptive activities of daily living techniques, physician oversight of post-operative 
risks and polypharmacy, and case manager coordination of any additional services that might be needed to 
make a sustainable return home, as well as avoid preventable readmissions to the acute hospital. Therefore, the 
requested inpatient rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Granix. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee is status post renal transplant with neutropenia. Granix is indicated to reduce the 
duration of severe neutropenia in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. The recommended dose of 
GRANIX is 5 mcg/kg per day administered as a subcutaneous injection. The review has determined that the 
requested use of Granix is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft at time of implant (D6104), guided tissue 
regeneration (D4266), endosteal implants (D6010), and a cone beam CT capture (D0367), provided on March 
3, 2023. 
 
You asked the Plan to pay for D6104, D4266, D6010, and D0367. You say that you do not feel responsible for 
these charges. The Plan denied your request. The Plan says the denied dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
graft at time of implant (D6104), guided tissue regeneration (D4266), endosteal implants (D6010), and a cone 
beam CT capture (D0367), provided on March 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97116 and 97530 billed for December 8, 
2022, to December 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 97116 and 97530 are 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 97116 is therapeutic procedure, 1 or more areas, each 15 
minutes; gait training (includes stair climbing). The definition of code 97530 is therapeutic activities, direct 
(one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT codes 97116 and 97530 are not supported in the medical record. Specifically, the records do 
not document the time spent performing the services to support codes 97116 for December 8, 2022 and code 
97530 for December 8, 2022; December 12, 2022; and December 29, 2022. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 97116 and 97530 billed for December 8, 2022, to December 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950 x2) and pontic (D6245). 
 
You asked the Plan to pre-approve core buildup and pontic. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950 x2) and pontic (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care, per day, for the evaluation and 
management of a patient (99233) provided on April 26, 2023. 
 
You asked the Plan to pay for subsequent hospital care. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says the medical records 
submitted do not support high level of medical decision making or total time required of the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 subsequent hospital care. Our reviewer says that the service 
does not meet criteria for payment on this claim. Our reviewer found the documentation does not support the 
level of 99233, as the documentation supports a consult. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for subsequent hospital care, per day, for the evaluation and management of a patient 
(99233) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for teeth #11, 12, 15 (D6740), prefabricated 
post and core in addition to a crown for tooth #11 (D2954), and pontic for teeth #13 and 14 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on dates of service April 21, 2021 and May 21, 2021. Therefore, we decided that the Plan does not have to pre-approve a crown for teeth #11, 12, 15 
(D6740), prefabricated post and core in addition to a crown for tooth #11 (D2954), and pontic for teeth #13 and 
14 (D6245).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve vacuum socket system. 
 
You asked the Plan to pre-approve vacuum socket system. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that vacuum socket systems are covered for certain 
indications. 
 
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 vacuum socket system. Our reviewer 
says that the documentation does support that the requested vacuum socket system is medically reasonable and 
necessary. Our physician reviewer found the enrollee has experienced a change in the volume of the enrollee's 
residual limb and the current prosthetic socket no longer fits the enrollee's residual limb despite attempted 
modification. The enrollee requires a new prosthetic socket for the prosthesis, which is necessary for mobility 
and performing daily activities. The vacuum assisted socket suspension system allows for the best fit and 
accommodation for the volume fluctuation and hyperhidrosis of the enrollee's residual limb throughout the day. 
There is medical literature indicating that this type of suspension system can be helpful in enrollees with 
volume fluctuation. Therefore, the vacuum assisted socket suspension system is 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 vacuum socket system have been met. Therefore, we decided that the Plan has 
to pre-approve vacuum socket system.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that proton beam therapy is medically 
necessary due to the enrollee's life-threatening diagnosis. The Plan denied your request. The Plan says there are 
not enough studies on proton beam therapy for breast cancer to show it is safe and effective. 
 
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 proton beam therapy. Our reviewer says 
that the requested proton beam therapy is not considered medically reasonable and necessary. Our physician 
reviewer found the National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer note that 
These studies suffer from the biases and talents of the investigators ... [and] dosimetric studies ... can suggest 
that the right treatment planning can make an IMRT plan beat a proton therapy plan and vice versa, they do not predict accurately clinically meaningful endpoints.  This applies to breast cancer as well which complicates 
reviews like this. For this patient, the records describe a case control comparison plan with proton therapy vs. 
photon. It does not describe the photon plan as using Volumetric Modulated Arc Therapy (VMAT) using deep 
inspiration breath hold, which would be the standard treatment and allow for the heart to pull away from the 
chest. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you would like to request reconsideration 
of the denied claim and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the records provided do not support the medical necessity for additional physical therapy visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the medical records provided there is no documentation that 
the requested therapy is generally accepted as specific and effective therapy for the patient's condition. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service March 17, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the clinical value benefits the enrollee. The Plan 
denied your request. The Plan says the billed code 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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. We find that 13 units of CPT 
code 87798 is not supported in the medical record. The records do not identify 13 organisms were tested for 
this code. 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 code 87798 billed for 
date of service March 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0453-59 and 95812 billed for June 10, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the -59 modifier is not supported for G0453 and code 95812 is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service. 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 95812 is electroencephalogram (EEG) extended 
monitoring; 41-60 minutes. 
 
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 these services. Our reviewer says that the -
59 modifier is not supported for G0453 and code 95812 is not supported. Our physician reviewer found the 
records do not support that code G0453 was distinct from procedure code 95812. The records document one 
continuous electroencephalogram (EEG) recording on June 10, 2023 for the surgery with no indication the 
procedures were separate or distinct; therefore, modifier -59 is not supported for code G0453. 
 
The records do not include the time to support that extended EEG monitoring of 41 to 60 minutes was 
performed to support code 95812. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes G0453-59 and 95812 billed for June 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services and infrared therapy provided on 
June 15, 2023. 
 
You asked the Plan to pay for the infrared therapy. You say that this claim should be reprocessed and paid. The 
Plan denied your request. The Plan says infrared therapy services are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that here is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the acupuncture services and infrared therapy provided on June 15, 2023.