Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's current condition requires 
an LTACH level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee has a past medical history significant for atrial fibrillation, stroke, 
diabetes, and an infected stage IV sacral wound. The enrollee has been dealing with gastrointestinal (GI) bleeds 
and requires intravenous (IV) antibiotics for osteomyelitis. The enrollees wound care needs are daily sacral 
wound changes and weekly changes to an ankle wound. This enrollee does not appear to be safe for transfer 
and requires additional time in current 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 this device is experimental, and more research is needed. 
 
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 the Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the request is medically necessary. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have 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 the enrollee is receiving post-operative care for complicated surgery that was 
performed at the current facility. Therefore, the enrollee is receiving services that are more appropriately 
provided at the current facility by the same surgical team. The enrollee would not require services at the 
LTACH that are not available at the current facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve budesonide delayed release capsules. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve budesonide delayed release 
capsules.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96374, 96375, 93005 and 93041 billed for 
date of service June 15, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services are not bundled. The Plan denied 
your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that codes 96374 and 96375 are column II codes to column I code 74174. 
Codes 96374 and 96375 have not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met. 
 
Codes 93005 and 93041 have a Q1 status indicator. This means that the payment for services is packaged into 
payment for services with a status indicator of S, such as billed code 99282. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 96374, 96375, 93005 and 93041 billed for date of service June 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 billed for date of service February 28, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the documentation supports the code. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. We find that CPT code 36556 is not supported in the medical 
record. The medical records note a urinary catheter. There is a more applicable code to describe the services 
provided. 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 procedure code 36556 billed for date of 
service February 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 13152 rendered on April 1, 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 the coding criteria for complex repair has not been met. 
 
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 13152 is "Repair, complex, eyelids, nose, ears and/or 
lips; 2.6 cm to 7.5 cm." 
 
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 CPT 13152 is not supported. The 
documentation states that the laceration repair was buccal. There is a more specific code for this procedure. The procedure in question was not coded to the highest specificity. 
 
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 13152 rendered on April 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130). 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 a total hip arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The provided records noted a failure of 
conservative measures on the November 21, 2023, treating physician report of injections, physical therapy, 
anti-inflammatories, weight loss, and activity modification. However, this is not clearly corroborated by 
documentation and/or dates/outcomes of the treatments. There are no significant clinical objective findings 
noted for the left hip. The enrollee is noted to have decreased motion (with no values attached.) There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty (27130).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service January 5, 2023, to 
April 14, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that a corrected 
claim is needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is enrolled in the Medicare 
program. Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, 
we decided that the Plan has to pay for the home health care billed for dates of service January 5, 2023, to April 
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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 18, 2023.

You asked the Plan to waive the copayment for the ultrasound. You say that this service was a part of your yearly exam. 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 $55 copayment for standard x-rays and ultrasounds.

You have been asked to pay a $55 copayment for the ultrasound. This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 the ultrasound provided on August 18, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that you are requesting reconsideration to 
aide with the chronic left knee pain which is increased and continues to bother the enrollee. The Plan denied 
your request. The Plan says the request is not medically necessary because based on the medical literature this 
procedure is considered experimental or investigational and has not been proven to be beneficial 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 genicular nerve blocks. 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 chronic left knee pain. She has had steroid injections as well as 
viscosupplementation. Her medication trials have included Gabapentin and Cymbalta. This is considered 
experimental therapy. It is the subject of ongoing clinical trials. 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance, when performed (64454).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy (15830). 
 
You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); 
abdomen, infraumbilical panniculectomy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because your records show you do not have 
chronic intertrigo that is refractory to medical therapy, difficulty walking or affecting activities of daily living 
and that the surgery is being requested for rectus diastasis for contouring. 
 
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 excision, excessive skin and 
subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that you have diastasis recti and a lax abdominal wall secondary to 
previous umbilical hernia surgery. The record provided does not document the presence of chronic intertrigo 
that consistently recurs or remains refractory to appropriate medical therapy over a period of 3 months or the 
presence of functional impairment. The surgery is requested for contouring as part of a diastasis recti repair, an 
excluded condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excision, excessive skin and subcutaneous tissue (includes lipectomy); 
abdomen, infraumbilical panniculectomy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical 
panniculectomy (15830).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 25, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the medical records support the billing. 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 find that CPT code 99285 is not supported in the medical record. The enrollee presented to the emergency 
department with tingling in the left arm for a week. The enrollee denied shortness of breath, chest pain, neck 
pain, fever and chills. The enrollee was in no acute distress. The enrollee remained stable throughout the 
evaluation. The records do not document a high level of medical decision making. 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 procedure code 99285 billed for date of service July 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
Health Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1833), suspension sleeve (L2397), and 
condylar pad (L2810), provided on June 14, 2023. 
 
You asked the Plan to pay for the knee orthosis, suspension sleeve, and condylar pad . You say that the items 
were medically necessary. The Plan denied your request. The Plan says the documentation requirements have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication these items were needed or ordered in the clinical documents submitted. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833), suspension sleeve 
(L2397), and condylar pad (L2810), provided on June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that you need this. The Plan denied your request. The Plan 
says that you do not meet criteria for this. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit any medical records related to your request. We 
requested supporting records, but none were submitted. Without supporting records, we cannot determine 
whether you meet Medicare criteria for a CGM. Therefore, the Plan has not shown that its decision to deny 
authorization is correct or medically justified. Therefore, we decided that the Plan has to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM).  
 
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.