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

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this procedure is medically 
necessary for the treatment of the enrollee's condition. The Plan denied your request. The Plan says this 
procedure is considered experimental and therefore cannot be 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 genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and 
necessary in this case. Our physician reviewer found there are no diagnostic imaging studies provided for 
review to corroborate left knee pathology. 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. While the studies are noted to be promising, further studies/research is needed to corroborate that geniculate 
artery embolization is as good as or better than standard treatments for knee osteoarthritis. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested genicular artery embolization 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
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 these services are medically necessary. The Plan 
denied your request. The Plan says these services can be provided safely in an alternate setting.  
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the 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 complexity of the enrollees medical, rehab, and nursing needs do not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. 
The enrollees rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled 
nursing facility (SNF) when the enrollee's medical condition is stable. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Hereditary Transthyretin-mediated amyloidosis 
test provided on April 17, 2023.  
You asked the Plan to pay for the Invitae Hereditary Transthyretin-mediated amyloidosis test. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The Invitae Hereditary Transthyretin-mediated amyloidosis test at issue in this appeal was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the Invitae Hereditary Transthyretin-mediated amyloidosis test provided on 
April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PALB2 gene analysis full gene sequence for date of 
service April 3, 2023.  
You asked the Plan to pay for the PALB2 gene analysis full gene sequence. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The PALB2 gene analysis full gene sequence test at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the PALB2 gene analysis full gene sequence for date of service April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 5, 2023, to May 8, 
2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
charges. 
 
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 the practitioner services provided have 
been met. Specifically, the documentation did not clearly state which specific procedure codes were being 
appealed. Therefore, we decided that the Plan does not have to pay for practitioner services provided on May 5, 
2023, to May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician attendance and supervision of hyperbaric 
oxygen therapy, per session (99183) and hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (G0277). 
 You asked the Plan to pre-approve hyperbaric oxygen therapy (HBOT). You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show the enrollee does not have failed thirty days of standard wound 
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 hyperbaric oxygen therapy (HBOT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a Wagner grade 3 diabetic foot ulcer. According to the 
records and letters of medical necessity, the enrollee was hospitalized on August 11, 2023. The ulcer was 
debrided. On September 6, 2023, the enrollee underwent fifth ray amputation. During a visit for evaluation for 
hyperbaric oxygen on September 15, 2023, the wound measured 8.3 x 2.7 x 2.0 centimeters. That is the only 
wound measurement found in the record, after the amputation. There is no documentation of failure of standard 
wound care after the amputation, and 30 days have not passed since the amputation. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy (HBOT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve physician attendance and supervision of hyperbaric oxygen therapy, 
per session (99183) and hyperbaric oxygen under pressure, full body chamber, per 30-minute interval (G0277).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 7, 2022, to 
July 11, 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 the 
enrollee was provided medically necessary services with the expectation that those services would be 
reimbursed according to the documentation in all communications. The Plan denied your request. The Plan 
says the review did not find sufficient documentation to clinically validate the diagnosis of A41.9 (Sepsis, 
unspecified organism) as the principal diagnosis. The Plan also says this recommendation results in a change 
from DRG 871 to DRG 189. 
 
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 principal diagnosis code, A41.9, defined as Sepsis, 
unspecified organism. 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 submitted DRG is not supported. Our 
physician reviewer found there was insufficient evidence to support the Sepsis 3 criteria was met as there was 
not a Sequential Organ Failure Assessment (SOFA) score of 2+ and no evidence to suggest the enrollee was 
experiencing organ failure directly related to a dysregulated response to infection as required to justify the 
code, A41.9 (sepsis).  
 
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 the inpatient hospital services provided from July 7, 2022, to July 11, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81274 for date of service February 25, 2022. 
 
You asked the Plan to pay for procedure code 81274. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing identified with code 81274 is 
unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as not medically necessary. 
 
We looked at the file and Medicare rules. Review of the file shows that the service at issue is identified with 
code 81274. This service is specifically not covered. Based on this information, we decided that Medicare rules 
for coverage of procedure code 81274 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 81274 for date of service February 25, 2022.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for 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 complexity of the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The clinical documentation shows that the enrollee would be expected to require continued 
physical and occupational therapy but does not justify the medical necessity of an intensive rehabilitation in an 
IRF 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 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a Marriage and 
Family Therapist on April 25, 2023. 
 
You asked the Plan to pay for the outpatient mental health services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this provider is ineligible to bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
 
 In this case, the provider of the services at issue is not one of the above-listed provider types. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does 
not have to pay for outpatient mental health services provided by a Marriage and Family Therapist on April 25, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says an electronic connection, harness, and expandable controller cannot be 
covered as it is not medically necessary to control the three requested power options through the joystick (drive 
interface). 
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has sufficient strength and 
function in upper extremities to manage standard power drives. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care and inpatient hospital care 
provided on May 4, 2023, to May 11, 2023. 
 
You asked the Plan to waive the copayment for emergency care and inpatient hospital care. You say that you 
disagree with the copayment. 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 $95 
copayment for emergency care and a $250 copayment per day for days 1-7 for inpatient hospital care.  
 You have been asked to pay a $95 copayment for emergency care and a $250 copayment per day for days 1-7 
for inpatient hospital care. The total amount you are being asked to pay for inpatient care is $1,750 ($250 x 7 
days = $1,750). The total amount you are being asked to pay for all services rendered is $1,845 ($1,750 + $95 
= $1,845). This item/service falls within the emergency care and inpatient hospital care 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. Therefore, we decided that 
the Plan does not have to waive the copayment for emergency care and inpatient hospital care provided on May 
4, 2023, to May 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the scan is not medically necessary. Our physician reviewer found the consult notes provided for review 
suggested that the member is only suspected of having behavioral-variant frontotemporal dementia (bvFTD). 
There was no mention of AD in the records provided for review. The base requirement of the NCD (to 
differentiate AD from FTD) would not have been met. Therefore, this service would not be eligible for 
coverage. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 30, 2023. 
 
You asked the Plan to pay for the office visit. You say that the provider is in-network with the Plan. 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 the office visit provided 
on May 30, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that these services are medically necessary for 
the enrollee. The Plan denied your request. The Plan says these services are not reasonable or medically 
necessary. 
 
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 the additional requested therapy is not generally accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the health plan. The records do 
not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. 
 
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 10 additional physical therapy visits.