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

 
We decided that the Plan does not have to pre-approve the seat lift mechanism (E0627) and accessories 
(E1399). 
 
You asked the Plan to pre-approve the seat lift mechanism and accessories. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 the seat lift mechanism and accessories. Our reviewer says that the enrollee does not need these items. Our physician reviewer found the provided 
records in this case do not document severe arthritis of the hip, a neuromuscular disease, or that a seat lift is 
included in the treating practitioner's course of treatment. 
 
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 seat lift mechanism and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the seat lift mechanism (E0627) and accessories (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready for admission once 
approved. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity imaging to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the lower extremity imaging from an OON provider. You say that you do 
not drive on highways or on the Beltline. You say that you would like to go to the requested OON provider and 
that the services required need to be done in a special setting due to health concerns. The Plan denied your 
request. The Plan says lower extremity imaging is available with network providers. The Plan says that services 
are required to be with Plan providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve lower extremity imaging to be provided by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care for evaluation and management of a patient (99223) 
billed for date of services April 3, 2023.  
 
You asked the Plan to pay for the initial hospital care for evaluation and management services. You say that the 
services provided were medically necessary.  The Plan denied your request. The Plan says that the services 
provided were not urgent or emergent and were not approved in advance.  
 
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. Specifically, the Plan did not provide any medical records or evidence of having 
made reasonable attempts to obtain medical records. Without this necessary information, we are unable to 
evaluate whether the hospitalist services were provided during a covered hospital stay, whether the services 
were provided in an out-of-network hospital prior to the enrollee being stabilized for transfer, or whether the 
services were urgent/emergent in nature. Therefore, we decided that the Plan has to pay for initial hospital care 
for evaluation and management of a patient (99223) billed for date of services April 3, 2023.   
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is a fall risk, and she is not back to her 
baseline. The Plan denied your request. The Plan says the enrollee has no daily skilled nurse or therapist needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthetic or steroid injections (64447, 64454) provided on 
February 6, 2023. 
 
You asked the Plan to pay for anesthetic or steroid injections. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (64640) provided on January 27, 2023. Based on this information, we decided that 
Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthetic or steroid injections (64447, 64454) provided on February 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are unable to walk without assistance. The Plan 
denied your request. The Plan says the SNF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require skilled nursing or skilled therapy services that require the 
specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. You do not require 
skilled services on a daily basis. You do not require skilled services on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (J7327). 
 You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says the step therapy 
criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Monovisc. Our reviewer says that the 
enrollee does not meet the coverage criteria for Monovisc. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (J7327).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you are appealing this denial. The Plan denied your 
request. The Plan says that this drug is to be dispensed by a pharmacy which is not covered by Medicare Part 
B. 
 
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 indicated that this Botox will be dispensed by a pharmacy rather than 
incident to the physicians services. However, the Plan did not submit evidence to support this position. We 
requested supporting evidence from the Plan, but none was submitted. Therefore, the Plan has not shown that 
its decision to deny authorization for this drug is correct or justified according to Medicare rules. Therefore, we 
decided that the Plan has to pre-approve Botox.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 28 additional routine-transportation trips. 
 
You asked the Plan to pre-approve 28 trips. You say that the requested services are a necessity for your care. 
The Plan denied your request. The Plan says you have exhausted your routine-transportation benefit for the 
year. 
 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 a maximum of 48 one-way trips per year.  
 
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 28 additional routine-transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0239U billed for date of service March 27, 
2023. 
 You asked the Plan to pay for procedure code 0239U. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says payment for code 0239U is bundled into payment for code 0037U. 
 
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, we have confirmed that code 0239U 
is a column II code to column I code 0037U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 0239U billed for date of service March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(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 this is considered 
experimental and therefore is not covered. 
 
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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause for the enrollee's pain. 
Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88341, 88342) billed for date of service 
March 3, 2023. 
 
You asked the Plan to pay for pathology services. You say that these services were necessary and are supported 
in the medical records. The Plan denied your request. The Plan says no medical records for the date in question 
were provided to support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of pathology services have been met. 
Specifically, the records provided are for pathology services performed on a specimen which was collected on 
March 6, 2023, and resulted/reported on March 30, 2023. No records were provided which would apply to a 
date of service of March 3, 2023. Therefore, we decided that the Plan does not have to pay for pathology 
services (88341, 88342) billed for date of service March 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service 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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) scan evident in the case record 
that shows only modic changes without facet degenerative joint disorder (DJD) or stenosis. 
 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).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25600-54 billed for April 25, 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 procedure code 25600-54 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 25600-54 is closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when 
performed; without manipulation. 
 
We find that CPT code 25600-54 is not supported in the medical record. Specifically, the records show that an 
ortho-glass splint was applied and the enrollee was instructed to follow up with an orthopedic provider in-
office; therefore, the -54 modifier is not supported. 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 code 25600-54 billed for April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 25, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider was not responsible 
for obtaining authorization. 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 subsequent nursing 
facility care provided on May 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 3, 2023, to April 
1, 2023. 
 You asked the Plan to pay for the home health services. You say that you originally submitted the NOA on 
March 5, 2023. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  The Plan says that although you contend that you submitted the NOA on 
March 5, 2023, there was no evidence this was submitted prior to its inclusion with your appeal request on June 
13, 2023. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 3, 2023. The NOA was not received by the Plan until June 13, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
March 3, 2023, to April 1, 2023.