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

 
We decided that the Plan does not have to pre-approve posterior lateral arthrodesis implant L4-5. 
 
You asked the Plan to pre-approve the implant. You say that this procedure is necessary to address pain and 
restore function. The Plan denied your request. The Plan says this procedure is not supported by research and is 
not 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 the implant. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Plan considers posterior lateral arthrodesis with cages experimental/investigational. 
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 implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve posterior lateral arthrodesis implant L4-5.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services (99285) provided on May 19, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 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 services. Our reviewer says that the use of code 99285 is not supported by the records provided. Our reviewer found that the documentation does not support a high 
level of medical decision-making, as the enrollee was stable and not complicated. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency services (99285) provided on May 19, 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 the provider feels it is not safe for the enrollee to 
return home at this time. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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 
was admitted for surgical repair of a hip fracture after a fall. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. 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 this patient 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the enrollee needs the level of 
care provided in the SNF. The Plan denied your request. The Plan says that the enrollee no longer meets the 
criteria for SNF care. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has had significant clinical and functional status changes post right femur 
fracture, which requires continued assessment by skilled nursing and skilled therapy. Clinical documentation 
supports the need for continued daily skilled services on an inpatient basis in a skilled nursing facility. 
Therefore, the request for continued SNF care is justified. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
skilled nursing facility (SNF) care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the enrollee's imaging did not show any modic changes of the 
spine, however it does show other degeneration in the spine that could be causing the enrollee's pain which is 
contraindicated in having the requested 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the magnetic resonance imaging (MRI) does not document modic endplate 
changes. Thus, this procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. The Plan denied your request. The Plan says your annual dental allowance amount has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit annual dental allowance amount was exhausted on date of service August 21, 2023. 
Therefore, we decided that the Plan does not have to pay for dental services provided on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for image guidance for placement of radiation therapy fields 
provided on April 24, 2023. 
 
You asked the Plan to pay for the billed service. You say that the guidance was necessary to provide safe 
outcomes for the enrollee's condition. The Plan denied your request. The Plan says daily imaging is not 
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 pay for the billed service. Our physician reviewer 
found that image guided radiation therapy (IGRT) is a means to improve set-up accuracy. IGRT uses daily 
image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows 
accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and 
thus allow reduction in the volume of normal tissues exposed to radiation. When treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. Daily simple simulations and/or IGRT 
for a technology for which need has not been established by published data or supported by consensus 
guidelines is not 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 billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for image guidance for placement of radiation therapy fields provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the requested service. You say that the enrollee has knee pain and cannot 
have surgery at this time. The Plan denied your request. The Plan says this is not the standard medical 
treatment for the enrollee's condition.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested service. Our physician 
reviewer found that a genicular nerve block is experimental treatment for knee pain. More research is needed to 
show its safety and efficacy. Therefore, the request is not medically reasonable or necessary. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a urology visit provided on September 06, 
2023. 
 
You asked the Plan to reduce the copayment for a urology visit. You say that this was supposed to be a $5 
copayment not $35. 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a urology visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 reduce the copayment for a urology visit provided on September 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan concurrently with a CT scan of the head. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has mild cognitive impairment and 
memory loss. A PET scan is needed to get a medication approved. 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 service is not medically necessary. Our physician reviewer found that the record indicates that the enrollee 
has a diagnosis of mild cognitive impairment in the setting of microvascular ischemic changes. The record 
provided does not establish that the enrollee meets the diagnostic criteria of both Alzheimer's disease and 
frontotemporal dementia or that the examination is being requested in the context of a clinical trial. 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan concurrently with a CT scan of the head.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-area oncologist. 
 
You asked the Plan to pre-approve these services. You say that you are unable to travel back to Utah. The Plan 
denied your request. The Plan says the services are not urgent or emergent and are available from in-network, 
in-area providers. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that you left the Plans service area with a known 
need for oncology care. 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 referral to an 
out-of-area oncologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49084 rendered on August 8, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says per coding guidelines, CPT 49084 is inherent to the primary laparoscopic procedure performed. 
 
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 49084 is "Peritoneal lavage, including imaging guidance, 
when performed." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that 49084 is not supported. The 
record does not contain evidence that a peritoneal lavage, diagnostic or therapeutic, was performed. The abdominal washout documented is part of the main procedure and not separately reported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 49084 rendered on August 8, 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 the enrollee will benefit from intensive rehabilitation 
with daily physician oversight and they are expected to make significant gains. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transcarotid artery revascularization (TCAR). 
 
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 that the services 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has potentially asymptomatic 
high-grade stenosis of the left internal carotid artery. Reports of the degree of stenosis range from greater than 
70 percent to greater than 80 percent. As the symptoms may be suggestive of symptomatic carotid stenosis, the 
need for treatment is strengthened. The services are therefore reasonable and medically necessary at this time. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve transcarotid artery revascularization (TCAR).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary as there is no need to control two or more power options 
through the joystick. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the request is for replacement of electronics on an existing power wheelchair. the enrollee has a 
hemiparesis from a brain injury. The enrollee is able to dress, toilet and feed herself. The enrollee has adequate 
strength 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311).