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

 
We decided that the Plan does not have to pre-approve the ankle-foot orthosis (L1990). 
 
You asked the Plan to pre-approve the ankle-foot orthosis. You say that the enrollee is under your care for 
spastic hemiparesis and well as other chronic medical conditions. You also say that the enrollee can no longer 
get up, walk or transfer in her home due to her current brace not fitting well and causing pain as well as skin 
breakdown. The Plan denied your request. The Plan says the notes do not show what type of brace this is or 
why it is not meeting the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is provided when the enrollee requires 
stabilization for medical reasons and have the potential to benefit functionally. 
 
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 ankle foot orthosis. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found according to Medicare, an ankle-
foot orthosis (AFO) can be covered if the enrollee requires the AFO due to weakness or deformity of the foot 
and ankle. It can be approved for those who require stabilization for medical reasons and have the potential to 
benefit functionally. In this case, the documentation doesn't support that the joint is unstable or that there is 
joint laxity. There is no indication that the current AFO requires replacement or that it is not meeting the 
enrollee's needs. The requested AFO orthosis 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 ankle-foot orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the ankle-foot orthosis (L1990).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 Endolite Echelon foot and Ottobock Dynion knee. 
 
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 a K3 microprocessor foot and knee 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 the ordering physician notes clearly 
indicate that the enrollee is at a functional level two ambulator. The criteria for coverage of the K3 
microprocessor knee and foot are not met and the services 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 a K3 Endolite Echelon foot and Ottobock Dynion knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on July 10, 
2023, by an OON provider.  
 
You asked the Plan to pay for the interrogation device evaluation. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this service is not covered 
when received by an out-of- network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network physician/practitioner services are not 
covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we 
decided that the Plan does not have to pay for the interrogation device evaluation provided on July 10, 2023, by 
an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on January 23, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the records provided support the method 
of transportation. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the services were not medically necessary. Our physician reviewer found the enrollee did not have a 
time-sensitive condition, requiring emergency services at a specialty hospital. The enrollee could have been 
taken by ground ambulance to the closest facility for initial evaluation. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on January 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided May 25, 
2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 the service. Our reviewer found the workup revealed no 
leukocytosis but with abscess on imaging and was treated with bedside, simple incision and drainage revealing 
hematoma. The procedure was tolerated without complication, and dressing was applied. The enrollee was 
discharged home. Although there was an appropriate history and examination documented, the documentation 
did not sufficiently support medical decision-making of high complexity as required to justify code 99285. The 
enrollee was relatively medically stable and did not require significant treatment changes or intervention. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit (99285) provided May 25, 2023.
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 delay in treatment will jeopardize enrollee's to return 
home at a safe functioning level. The Plan denied your request. The Plan says the coverage criteria has 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy in an 
intensive rehabilitation therapy program. Medically necessary care can be provided in a different level of care. 
There is no reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01992 performed 
on date of service March 27, 2023. 
 
You asked the Plan to pay for 01992. You say that 01992 should be paid as billed because it is supported in the 
medical record and was billed with the same diagnosis codes used by the surgeon. The Plan denied your 
request. The Plan says 01992 is denied because it was billed without the required modifier -QS, and the 
diagnosis codes assigned do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that when MAC is provided and procedure code 
01992 is billed, modifier -QS must be used. The rules also say that diagnosis codes M54.16 and M46.1 are not 
listed as diagnosis codes that support medical necessity when billing procedure code 01992.  
We looked at the file and Medicare rules. In this case, the medical records contain evidence that MAC was 
provided. We confirmed that procedure code 01992 was billed without modifier -QS. Modifier -QS is required 
for reporting 01992 when MAC was provided, as it was in this case. We have also confirmed that procedure 
code 01992 was billed with diagnosis codes M54.16, defined as radiculopathy, lumbar region, and M46.1, 
defined as sacroiliitis, not elsewhere classified. No additional diagnoses were listed on the claim. Per LCA 
A57361, M54.16 and M46.1 do not support medical necessity when billing 01992. As such, the denial of 
01992 is appropriate. Based on this information, we decided that Medicare rules for coverage of 01992 have 
not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services described by 
code 01992 performed on date of service March 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you have not been able to stand in over 
three months and you are getting weaker. You need rehabilitation in a LTACH. The Plan denied your request. 
The Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 You asked the Plan to pre-approve Gel-One. You say that you need this done for your knee problem. You say 
that your orthopedic doctor advised this is the best way to treat your knee pain. You also say that the doctor 
advised the other medications listed would not work for your problem. The Plan denied your request. The Plan 
says the enrollee has not tried and failed the preferred drugs, Durolane, Euflexxa, GelSyn-3, and Supartz FX. 
 
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 Gel-One. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the preferred drugs. The reviewer also found that there is no documentation 
provided indicating that the Plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on March 
15, 2023, to April 6, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 will be denied as not reasonable 
and necessary. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on March 15, 2023, to April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair of nonunion or malunion, radius OR ulna; without 
graft (24500-LT) provided July 14, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 24500 is repair of nonunion or malunion, radius OR ulna; 
without graft (for example, compression technique). 
 
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 the service. Our reviewer found for code 24500-LT, the documentation does not meet criteria for billing or reimbursement consideration. The medical records provided 
do not include sufficient documentation to validate that a repair of nonunion or malunion, radius OR ulna; 
without graft (for example, compression technique) was performed on July 14, 2023; therefore, this procedure 
cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for repair of nonunion or malunion, radius OR ulna; without graft (24500-LT) provided July 14, 
2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the member can highly benefit from the 
physical therapy services. The Plan denied your request. The Plan says the requested services are not medically 
reasonable and 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 requested therapy is not generally accepted as specific and 
effective therapy for the patients condition. 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. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current 
condition or to prevent or slow further deterioration. 
 
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 physical therapy (PT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from June 7, 2023, to June 
8, 2023. 
 You asked the Plan to pay for the inpatient admission. You say that the provided services were medically 
necessary. You also say that the patient required aggressive inpatient treatment for greater than 2 midnights that 
could not have been safely done at home or on an outpatient basis. The Plan denied your request. The Plan says 
medical necessity has not been established. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission it was reasonable for 
the admitting physician to expect that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights with supporting documentation of the patients 
history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided from June 7, 2023, to June 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that the enrollee is unable to do regular activities 
of daily living and a home health aide would be very beneficial. The Plan denied your request. The Plan says 
the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that based on the 
medical records provided, there is no documentation that the services meet the definition of home health aide 
services, or that the home health aide services are reasonable and necessary to the treatment of the enrollees 
illness or injury by the skilled professional staff. Furthermore, medical records provided in this case do not 
document that the enrollee has an inability to perform self-care or activities of daily living to meet Medicare 
criteria for the requested home health aide services. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. Since there are other alternatives, LTACH 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.