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

 
We decided that the Plan does not have to pre-approve a vertebral corpectomy. 
 
You asked the Plan to pre-approve a vertebral corpectomy. You say that the requested vertebral corpectomy is 
medically necessary. The Plan denied your request. The Plan says there is no evidence an extra amount of bone 
needs to be removed. A corpectomy is removal of all or most of the bone supporting the spine in front. It is 
only medically necessary in very specific circumstances, not present in this case.  
 
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 vertebral corpectomy. Our reviewer 
says that the requested vertebral corpectomy is not considered medically reasonable and necessary. Our 
physician reviewer found that you were being treated for spinal stenosis of the cervical region; cervical disc 
degeneration; and radiculopathy of the cervical region. You presented with significant improvement in neck pain with heat and time. You have intermittent numbness and tingling in the bilateral arms that is unchanged 
for several years. The pain is rated at 3 in the neck and 0 in the arm on the Visual Analogue Scale (VAS). The 
exam reveals gait is wide based. There is tenderness with flexion and extension. Strength and sensation are 
intact. Hoffmans test is positive bilaterally. However, detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures is not evident. Additionally, there 
is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective 
and/or safe treatment for the noted pathology. No compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
vertebral corpectomy 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 a vertebral corpectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vertebral corpectomy.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the microprocessor controlled knee (L5828, L5845, L5848, 
L5856), and flex walk-style foot with multi-axial ankle and active dorsiflexion (L5981, L5968). 
 
You asked the Plan to pre-approve the microprocessor controlled knee, and flex walk-style foot with multi-
axial ankle and active dorsiflexion. You say that the items are medically necessary. The Plan denied your 
request. The Plan says that the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the microprocessor controlled knee, and 
flex walk-style foot with multi-axial ankle and active dorsiflexion. Our reviewer says that the requested items 
are considered medically reasonable and necessary in this case. Our physician reviewer found the change in 
residual limb shape and increase in functional status constitute physiological change necessary to justify 
replacing his prosthesis at this juncture. 
 
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 microprocessor controlled knee, and flex walk-style foot with multi-axial 
ankle and active dorsiflexion have been met. Therefore, we decided that the Plan has to pre-approve the 
microprocessor controlled knee (L5828, L5845, L5848, L5856), and flex walk-style foot with multi-axial ankle 
and active dorsiflexion (L5981, L5968).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in desperate need for inpatient rehabilitation 
and you're moving in the right direction towards your goals. The Plan denied your request. The Plan says you 
do not meet the requirements for rehabilitation admission. Services needed may be provided safely in a lower 
level of care. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 27, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. 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). at the time services were provided the enrollee was residing in an assisted living 
facility. Therefore, we decided that the Plan does not have to pay for the home visit provided on March 27, 
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 admission to a SNF is medically necessary. The 
Plan denied your request. The Plan says admission to a SNF does not meet criteria. 
 
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 has metastatic esophageal cancer and dementia. From a nursing 
perspective, the enrollee received enteral nutrition and oral or enteral medications. The enrollee had stable vital 
signs. There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service 
needs. The enrollee does not require skilled nursing or therapy services on a daily basis. He does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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: 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 the physician and physical therapist highly 
recommend the enrollee to go to inpatient rehabilitation. He needs to get his strength back through intense 
physical therapy at the inpatient rehabilitation facility. The Plan denied your request. The Plan says based on 
the available information, admission to IRF is not reasonable and necessary, as the enrollee's condition does not 
meet the Medicare rules. 
 
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 is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. No acute rehabilitation nursing needs are 
identified. The complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) 
do not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative 
care. The enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as 
in a skilled nursing facility. 
 
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 pay for injections provided on March 01, 2023. 
 
You asked the Plan to pay for injections. You say that you say that obtaining authorization should be the 
surgeon/facilities responsibility. 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 injections provided on 
March 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
April 24, 2023. 
 
You asked the Plan to waive the copayment for an electrocardiogram (ECG). You say that you have never had 
to pay for this service before. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for each in-network Medicarecovered diagnostic procedure and test performed by a provider other 
than your primary care physician.  
You have been asked to pay a $75 copayment for an electrocardiogram (ECG). This item/service falls within 
the each in-network Medicarecovered diagnostic procedure and test performed by a provider other than your 
primary care physician benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. However, since the allowed amount is less than the standard copayment, you only owe 
$14.08. Therefore, we decided that the Plan does not have to waive the copayment for an electrocardiogram 
(ECG) provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves. 
 
You asked the Plan to pre-approve the RFA procedure. You say that it is felt that this would be useful in 
reducing knee pain. The Plan denied your request. The Plan says this is not a proven procedure. 
 
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 RFA procedure. Our reviewer says 
that the RFA procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is 66 years old with chronic knee pain, who has had relief with prior RFA of the 
genicular nerves. However, this procedure is considered experimental/ investigational at this time. It is the 
subject of ongoing clinical trials to determine its role in knee osteoarthritis. Therefore, the request is deemed 
not medically reasonable and 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 RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
March 21, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you thought this was 
covered in full by the Plan. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for in-network outpatient surgery provided at an ambulatory surgical center. 
 
You have been asked to pay a $275 copayment for the diagnostic colonoscopy. This item/service falls within the in-network outpatient surgery provided at an ambulatory surgical center benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The records show a diagnostic 
colonoscopy was provided, and the outpatient surgery copayment was correctly applied. Therefore, we decided 
that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on March 21, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 10, 2022, to 
January 8, 2023. 
 You asked the Plan to pay for the home health services. You say that you are a Medicare-certified provision 
and no authorization is required. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
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 December 10, 2022. The NOA was not received by the Plan until January 
9, 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 December 10, 2022, to January 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the vent has the ability to automatically 
adjust pressure support to maintain a target tidal volume and monitor the enrollee's upper airway resistance and 
adjust to the delivered expiratory positive airway pressure (EPAP) to maintain airway patency. The Plan denied 
your request. The Plan says the request for a ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has obesity 
hypoventilation syndrome, obstructive sleep apnea, continuous positive airway pressure (CPAP) intolerant, and 
heart failure with reduced ejection fraction (HFrEF). There is no diagnosis of COPD, thoracic restrictive 
disease, or neuromuscular disease. The enrollee was admitted July 21, 2023, for exacerbation of heart failure 
and atrial fibrillation with a rapid ventricular response. An arterial blood gas (ABG) showed mild compensated 
carbon dioxide (CO2) retention. Medicare does not cover a home ventilator for the treatment of obesity 
hypoventilation syndrome, or when used at settings that can be provided with bilevel positive airway pressure 
(BiPAP). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80307 billed for date of service December 
20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the code. 
 
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 80307 is presumptive drug testing for any number of 
drug classes per date of service. We find that CPT code 80307 is not supported in the medical record. 
Specifically, the records provided do not included lab results.  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 80307 billed for date of 
service December 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 22, 2022, to August 
20, 2022.  
You asked the Plan to pay for the home health services. You say that the claim lines are billable and are 
covered charges. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
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 July 22, 2022. The NOA was not received by the Plan until February 6, 
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 
on July 22, 2022, to August 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 4, 2022, to May 
9, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the records do not support the billing of 
diagnosis code N17.0. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N17.0. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the records do not support the billing of diagnosis code N17.0. Our physician reviewer found the enrollee 
presented to the hospital with symptoms of pneumonia, which was diagnosed after imaging and a physical 
examination. Upon workup, his creatinine was found to be 1.5 mg/dL and his blood urea nitrogen (BUN) was 
at 32 mg/dL. He was given intravenous (IV) fluids and creatinine was reduced to 1.1 with BUN of 20. Later, 
the creatinine went down to 0.8 and BUN to 4. He did not have oliguria or anuria or other signs of kidney 
failure. The records therefore do not support the billing of N17.0 (acute kidney failure).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 4, 2022, to May 9, 2022, at the Diagnosis Related Group 
(DRG) originally billed.