Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat diagnostic medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat MBBs 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee had a diagnostic MBB 
on February 2, 2023 that provided 75 percent pain relief. The Medicare rules require an 80 percent or greater 
pain relief result prior to a repeat MBB. Given that the criteria are not met, the requested repeat MBBs are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat diagnostic medial branch blocks (MBBs).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. You say you would like to do more therapy and be able to return back home and take care of 
yourself. 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on September 22, 
2022, and subsequent observation care (99226) provided on September 23, 2022. 
 
You asked the Plan to pay for initial observation care (99220) and subsequent observation care (99226). You 
say that the documents should be reviewed, and the decision should be reconsidered. The Plan denied your 
request. The Plan says procedure codes 99220 and 99226 are not supported by the medical records submitted. 
 
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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit.  
 
The CPT Code Manual definition of code 99226 is subsequent observation care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A 
detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has 
developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
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 initial observation care (99220) and subsequent observation 
care (99226). Our reviewer says that procedure codes 99220 and 99226 are not supported. Our reviewer found 
the documentation did not clearly show a comprehensive or detailed history or physical, nor was there evidence 
of decision-making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial observation care (99220) and subsequent observation care (99226) have 
not been met. Therefore, we decided that the Plan does not have to pay for initial observation care (99220) 
provided on September 22, 2022, and subsequent observation care (99226) provided on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355). 
 
You asked the Plan to pre-approve the dental services. 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 that the enrollee had a comprehensive exam (D0150) on March 30, 2023. Thus, the enrollee is not yet eligible to have D4355 performed. Therefore, we decided that the Plan does not have to pre-approve full mouth 
debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI. You say that you are requesting reconsideration for the denial of an 
MRI of the lumbar spine. The Plan denied your request. The Plan says the enrollee has not completed six 
weeks of provider directed treatment. 
 
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 
service is not medically necessary. Our physician reviewer found the enrollee is noted to have a history of low 
back pain. The enrollee underwent an MRI of the lumbar spine in July of 2022 and was noted on exam to have 
lower extremity weakness that was described as being in a myopathic pattern/distribution. An MRI of the spine 
is not commonly performed in the evaluation of a myopathy, nor would it be expected to be diagnostic in such 
a manner either. 
 
 
 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 not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you are requesting an additional 36.8 miles for a total of 86.8 miles and 
your benefit only allows 50 miles. The Plan also says you have exceeded your benefit limit. 
 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 up to 72 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies (A4221, A4222) provided on August 13, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says a proof of delivery was 
not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of delivery provided is not for the date of service in question. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the supplies (A4221, A4222) provided on August 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not tried physical therapy. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for osteoarthritis of the left knee. She does not like anti-
inflammatories. The exam reveals left knee full extension and flexion to 110. She has mild varus alignment and 
medial pseudolaxity. She has medial joint line tenderness. There is some mild patellofemoral crepitance. Her 
quadriceps and hamstring tone is a little diminished. Detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures including corticosteroid injections 
is not evident.  She recently had left knee physical therapy for 5 visits, without any follow-up or discharge note to corroborate 
failure to improve. Additionally, no provider exams have been provided since December 27, 2022. Updated 
imaging is not provided to corroborate the pathology of the left knee. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request. Therefore, the requested total 
knee arthroplasty, in this case, 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transluminal dilation of aqueous outflow canal. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is not 
the standard of care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that there is insufficient evidence in the published clinical literature to determine the safety and 
efficacy of goniotomy (e.g., OMNI transluminal dilation) for all other glaucoma types except pediatric 
glaucoma. Further research is warranted to better understand who would most benefit as well as, its long-term 
safety and efficacy. There is no supporting information in this case suggesting that goniotomy is the last 
therapeutic option for this enrollee despite its lack of clinical evidence by way of comparative controlled cohort 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transluminal dilation of aqueous outflow canal.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intense therapy in an IRF 
setting in order to get stronger. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 48-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation for 
cancer treatment. The Plan denied your request. The Plan says the requested trips exceed your transportation 
benefit. 
 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 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 additional trips for routine transportation beyond the Plan's 
48-trip limit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 14, 2021, to 
February 12, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that a plan of care must be submitted for home health services.  
 
We reviewed the file and the Medicare rules. We find that the a plan of care or medical records that include  
valid orders or visit note documentation for the billed visits in this billed episode of care. This claim is not 
payable as billed. Based on this information, we find that the Medicare rules for payment of the claim at issue 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from January 14, 2021, to February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 
not been met. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge. 
 
You asked the Plan to pre-approve a dental bridge. You say that the enrollee is a strong gagger. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
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.  
 
We looked at the file, and Medicare rules. The Plan guidelines show that the placement of a fixed prosthetic 
appliance will only be considered for those cases where there is a documented physical or neurological disorder 
that would preclude placement of a removable prosthesis. The records provided do not show a physical or 
neurological disorder.  Based on this information, we decided that the Plan's rules for coverage of a dental bridge have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a dental bridge.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image-Guided Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that you are requesting the Plan to review, reprocess, and 
approve the requested treatment according to the contract as a medical necessity. The Plan denied your request. 
The Plan says the request is denied because picture studies are not supported to guide the enrollee's type of 
treatment. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on community standards of care, the biopsied lesions do not require treatment with 
Image-Guided Radiation Therapy. The NCCN states, Protracted fractionation is associated with improved 
cosmetic results and should be utilized for poorly vascularized or cartilaginous areas. There is no 
recommendation for daily IGRT. The use of certain types of radiation equipment does not by itself make IGRT 
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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image-Guided Radiation Therapy (IGRT) (G6001).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on December 30, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says we are not responsible for the charges. Services from non-contract providers are not covered under 
open access unless preauthorized. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that ambulance transport was not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the enrollee's residence to the dialysis 
appointment was not medically necessary. The enrollee did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport.  Transportation could have 
been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the 
enrollee'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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on December 30, 2022.