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

 
We decided that the Plan does not have to pay for the Levocarnitine and Cyanocobalamin Injections provided 
on August 21, 2023. 
 
You asked the Plan to pay for the Levocarnitine and Cyanocobalamin Injections. You say that the injections 
were necessary for the enrollee. The Plan denied your request. The Plan says that these drugs are not effective 
and are experimental and investigational for the neuro stim therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pay for the Levocarnitine and Cyanocobalamin 
injections for electrostimulation therapy. Our reviewer says that the record indicates that the requested service 
is to be used in conjunction with electrostimulation therapy for an enrollee with leg pain and paresthesia. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug 
in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 
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 Levocarnitine and Cyanocobalamin Injections have not been met. Therefore, 
we decided that the Plan does not have to pay for the Levocarnitine and Cyanocobalamin Injections provided 
on August 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Botox. 
 
You asked the Plan to pre-approve Botox. You say that you are planning to treat the enrollee with Botox to 
help symptoms. The Plan denied your request. The Plan says gastroparesis is not a condition for which Botox is 
covered. 
 
The Plan follows Medicare rules. Medicare rules state that Botox may be covered for FDA labeled indications 
or for certain specified off-label indications. 
 
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 Botox. Our reviewer says that the 
enrollee does not meet criteria for Botox. Our physician reviewer found gastroparesis is the condition for which 
intrapyloric Botox injection is proposed. Gastroparesis is not a condition for which Botox is covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Botox.
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 enrollee is extremely motivated to return home 
safely but feels additional therapy is needed to regain their strength prior to returning home. 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 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. 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.  
 
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 office visit and application of multi-layer compression 
system provided on January 11, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that corrected claims are allowed up to 1 year 
from the last processed date which was January 29, 2022. You also say that the corrected claim was submitted 
on January 3, 2023. The Plan denied your request. The Plan says the corrected claim was not submitted timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 The record shows that a corrected claim for the outpatient services was not filed until May 10, 2023. This 
means that more than one calendar year from the date of the initial determination or redetermination had passed 
before a corrected claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit 
and application of multi-layer compression system provided on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (87150, 87481, 87653) provided on 
January 23, 2023. 
 
You asked the Plan to pay for lab tests. You say that documentation supports these tests. The Plan denied your 
request. The Plan says these codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. The CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, 
amplified probe technique. The CPT Code Manual definition of code 87653 is infectious agent detection by 
nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe 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 lab tests. Our reviewer says that these codes are not 
supported for coverage. Our reviewer found these tests were not found in the medical records submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing (87150, 87481, 87653) provided on January 23, 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 you are requesting reconsideration of the denied IRF 
admission. The Plan denied your request. The Plan says IRF care is not reasonable and 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 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. While the 
medical records support a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415 and 80048 billed for date of service 
May 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code is valid and appropriate. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that diagnosis code group I50.2 has an Excludes1 note in relation to diagnosis 
code group I50.4-. This means that diagnosis codes I50.40 and I50.22 cannot be reported together. Based on 
this information, we decided that the Medicare billing rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 36415 and 80048 billed for date 
of service May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (77399). 
 
You asked the Plan to pre-approve IGRT. You say that you are requesting reconsideration for radiation 
therapy. The Plan denied your request. The Plan says you do not meet criteria for approval of IGRT. 
 
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 the requested IGRT is not medically necessary for the type of basal cell carcinoma in this case. 
 
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) (77399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861, E0955, E2620, E1007, E2311, E1028, E2607, E2377, E2313, K0108, E1028, E1028, K0108, 
E1012, K0040, E2361, E0956, E0953 and E2300). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices 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 a group 3 power wheelchair with 
multiple power options. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. 
 
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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options (K0861, E0955, E2620, E1007, E2311, E1028, E2607, E2377, E2313, K0108, E1028, E1028, 
K0108, E1012, K0040, E2361, E0956, E0953 and E2300).
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 a fall risk, and you have no assistance when 
you go home. The Plan denied your request. The Plan says a skilled nursing facility, home with home health 
services or home with outpatient therapy. 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 the complexity of the patient's nursing, medical and rehabilitation can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on July 10, 
2023, to, July 17, 2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you were unable to walk due 
to your sciatic nerve being pinched in your spine. You say that you had to go for manipulation of the spine so 
that the nerve would loosen up for you to walk. The Plan denied your request. The Plan that the only covered 
chiropractic service is manual manipulation of the spine.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
  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 chiropractic manipulative treatment. Our 
reviewer says that chiropractic maintenance therapy is not a covered benefit. Our physician reviewer found that 
records indicates that the enrollee has lumbar pain and radiculopathy. However, the records of these visits do 
not support progressive improvement of symptoms but rather maintenance therapy. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
Therefore, the elements of the coverage criteria are not satisfied, and the requested service is not recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic manipulative treatment have not been met. Therefore, we decided 
that the Plan does not have to pay for chiropractic manipulative treatment provided on July 10, 2023, to, July 
17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the enrollee 
has chronic knee pain. However, there is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service. Also, the records do not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the elements of the coverage 
criteria are not satisfied, and the requested service is not recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
1, 2023, to January 31, 2023. 
 You asked the Plan to pay for the SNF care. You say that the services should be covered under the Medicare 
Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay from 
January 1, 2023, to January 31, 2023. 
 
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 pay for the 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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from January 1, 2023, to January 31, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit (99285) provided on June 14, 2023. 
 
You asked the Plan to pay for 99285. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says that there is insufficient documentation to support this service. 
 
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 99285. Our reviewer says that this code meets criteria for 
payment. Our reviewer found the record supports a high level of medical decision-making. The chief complaint 
included chest pain, which is high, a threat to life/function. The data reviewed is high, more than 3 unique tests 
were ordered and 1 interpretation was performed by the emergency department physician. The risk was high, a 
parenteral controlled substance was administered. This meets criteria to report high medical decision making, 
or 99285. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99285 have been met. Therefore, we decided that the Plan has to pay for an 
emergency department visit (99285) provided on June 14, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.