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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are still in need of SNF care at this time. The 
Plan denied your request. The Plan says you appear to have optimized your progress through skilled therapy 
services and at this time your needs may be provided at a lower level of 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gel-center mount/ artic footplate (K0108), and 
electronic connection (E2311). 
 
You asked the Plan to pre-approve a gel-center mount/ artic footplate, and electronic connection . You say that 
the items are medically necessary. The Plan denied your request. The Plan says a gel-center mount is an item of 
convenience, and the electronic connection is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the was correct in denying the request to pre-approve the electronic connection and footplate. Our reviewer found that the items are not medically necessary. The enrollee has sufficient strength and function in 
upper extremities to manage standard power drives and the footplate is for comfort. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a gel-center mount/ artic footplate (K0108), and electronic 
connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ambulatory infusion pump (E0781), and supplies 
(A4222, A4221). 
 
You asked the Plan to pre-approve an ambulatory infusion pump and supplies. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this is covered for the indications listed 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 an ambulatory infusion pump and 
supplies. Our reviewer says that the items are not medically necessary. Our physician reviewer found the 
patient does not have an indication that meets LCD criteria for use of an ambulatory infusion pump 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ambulatory infusion pump and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ambulatory infusion pump (E0781), and supplies 
(A4222, A4221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit and an x-ray provided on 
May 5, 2023. 
 
You asked the Plan to waive the copayments for an office visit and an x-ray. You say that you disagree with the 
copayments. 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 $10 
copayment per visit, to a specialist. Your contract with the Plan also clearly says that you must pay a $5 
copayment for each Medicare-covered x-ray in physician office. You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay a $5 copayment for an x-ray. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have been asked to pay a total of $15 ($10 copayment + $5 
copayment = $15). 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 copayments for an office visit and an x-ray 
provided on May 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3-4 transforaminal lumbar interbody fusion (TLIF) 
and posterior segmental instrumentation. 
 
You asked the Plan to pre-approve L3-4 TLIF and instrumentation. You say that this surgery is important for 
the enrollee. The Plan denied your request. The Plan says multi-level fusion is considered 
experimental/investigational and the Plan already approved L4-5 TLIF. 
 
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 L3-4 TLIF and instrumentation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no instability, fracture, or lesion at L3-4. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3-4 TLIF and instrumentation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve L3-4 transforaminal lumbar interbody fusion (TLIF) and posterior 
segmental instrumentation.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary as the enrollee 
has been bed bound and requires therapy services to return to prior level of function. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record significantly complies with the various documentation requirements for IRF 
admission. The enrollee's condition is in complex and fragile. There is every reason to expect that the enrollee 
will participate in and benefit from services to include at minimum physical, occupational and speech therapy, 
nutritionist, physician oversight of their various comorbidities, polypharmacy, urinary function, and case 
manager coordination of any additional services that might be needed to make a sustainable return 
home. Therefore, the requested inpatient rehab facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 L1 and L2 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L1 and L2 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L1 and L2 kyphoplasty. Our reviewer 
says that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation 
is not evident regarding worsening pain. The documentation does not corroborate current treatment for or a 
diagnosis of osteoporosis. There is no indication of a progression of the body height loss, kyphotic deformity, 
or a severe impact on daily activities. Moreover, there is magnetic resonance imaging corroboration of 
retropulsion and other plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 and L2 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 billed for date of 
service April 25, 2023. 
 You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed 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. 
 
We find that CPT codes 96365, 96366, and 96521 are not supported in the medical record. Outpatient 
intravenous insulin therapy is not a covered benefit. The records do not show that the refiling and maintenance 
of a portable pump was provided. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 96365, 96366, and 96521 billed for date of service April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular compression unit (VCU) system, provided on 
January 11, 2023, through January 31, 2023. 
 
You asked the Plan to pay for the VCU system. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the billed CPT code does not accurately describe the device provided. 
 
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 E0217 is a water circulating heat pad with pump. 
 
We find that CPT code E0217 is not supported in the medical record. Specifically, E0217 is not a covered item. 
Based on this information, we decided that Medicare rules for coverage of the VCU system have not been met. 
Therefore, we decided that the Plan does not have to pay for the vascular compression unit (VCU) system, 
provided on January 11, 2023, through January 31, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on October 16, 2022, to October 
21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.9 is 
supported in the record, therefore the claim should be paid at the original DRG. The Plan denied your request. 
The Plan says that A41.9 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
In this case, you billed the inpatient services provided with secondary diagnosis code A41.9, defined as sepsis, 
unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that diagnosis A41.9 is supported in the records. Our 
physician reviewer found the enrollee meets criteria for systemic inflammatory response syndrome and had a 
urinary tract infection, so A41.9 is justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on October 16, 2022, to October 21, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional physical therapy visits (97164). 
 
You asked the Plan to pre-approve the therapy services. 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. 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 your 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. The records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. 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 your current condition or to prevent or slow further deterioration. You have had extensive 
prior therapy and have had instruction in a home exercise program. Your functional deficits do not require 
ongoing formal therapy and can be safely and effectively be met with a home exercise program. 
 
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 2 additional physical therapy visits (97164).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array, epidural. You 
say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 
necessary.  
The Plan follows Medicare rules. Medicare rules say that implantation of stimulators can be covered under 
specific 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 percutaneous implantation of 
neurostimulator electrode array, epidural. Our reviewer says that the enrollee does not meet criteria for 
coverage. Our physician reviewer found there is no psychological evaluation and clearance. There is no 
surgical consultation to address the disc protrusion and facet pathology noted in the computed tomography 
scan. There is no documentation of a multi-disciplinary approach and conservative therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array, epidural have not 
been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of 
neurostimulator electrode array, epidural (63650).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75710, 75630, 36200, and 99153 billed for 
date of service December 19, 2022. 
 
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 billed 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, we have confirmed that codes 75710, 75630, 36200 are column II codes to column I code 37225. 
The medical records do not show that the services billed with the -59 modifier were distinct procedural services 
not ordinarily encountered with the main procedure. Based on the claim submitted, Medicare billing criteria 
have not been met. 
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. 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 75710, 75630, 36200, and 99153 billed for date of service December 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an ultrasound. You say that the services should be covered. The Plan denied 
your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ultrasound to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that you are 
requesting reconsideration and have provided medical records for review. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the lymphedema extends 
into the chest, trunk or abdomen. In addition, Medicare Guidelines say the E0652 is not reasonable and 
necessary for chronic venous insufficiency. Therefore, we decided that the Plan does not have to pre-approve a 
pneumatic compression device (E0652) and a segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 11, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not be liable for the charges for the ambulance, no transport, because you did not call the ambulance. The Plan 
denied your request. The Plan says you refused to be transported and signed the run report acknowledging 
refusal stating that you did not feel the need to be transported. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 11, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 11, 2023.