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

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI), also known as a 
nuclear stress test. 
 
You asked the Plan to pre-approve the requested MPI. 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 stress testing with imaging may be covered when 
reasonable and necessary for 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 requested MPI. Our reviewer says 
that the documentation does not support that there is a medically necessary indication for this testing. Our 
physician reviewer found Myocardial Perfusion Imaging in this individual with chronic heart failure, normal 
LV systolic function, chronic atrial fibrillation, and no angina does not meet the criteria for the stress test. The 
enrollee does not benefit from this testing and exposes the enrollee to unwarranted radiation. 
 
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 MPI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve myocardial perfusion imaging (MPI), also known as a nuclear stress test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested CGM is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
and has had no recent episodes of hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM and related supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CGM and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ankle foot orthosis (L4631). 
 
You asked the Plan to pre-approve the ankle foot orthosis. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as 
the record does not indicate the enrollee requires a replacement at this time. 
 
The Plan follows Medicare rules. Medicare rules say that that supportive devices for the feet (such as orthotics) 
are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows 
these same rules.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ankle foot orthosis. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found that the provided records do not 
document that the enrollee's current AFO has been lost, stolen, irreparably damaged in a specific accident or 
natural disaster or has reached its reasonable useful lifespan to meet Medicare criteria for replacement.  
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ankle foot orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ankle foot orthosis (L4631).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage of behavioral health inpatient psychiatric 
treatment from May 24, 2023, and forward. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the enrollee is still in the 
hospital and needs to go to a rehabilitation facility. The Plan denied your request. The Plan says the enrollee is 
not showing behavior that is interfering with her day-to-day function. She no longer has a need for treatment 
provided by or requiring the supervision of inpatient psychiatric facility personnel.  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found it was not expected this 
enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or 
homicidal ideation, auditory or visual hallucinations. The enrollee was compliant with treatment while not 
showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as she did not have dangerousness to self or others and was compliant with her treatment. The health plans 
denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require 
inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and 
does not have auditory or visual hallucinations. It did not appear that active treatment was taking place beyond 
the date in question. It did not appear that the services were reasonably expected to improve the enrollees 
condition or for the purpose of diagnosis beyond the date in question. The reviewer is unable to find an 
individualized treatment plan however the entire record is not present. It did appear that the records were 
supervised and evaluated by a physician. Based upon review the records provided for the admission of this 
enrollee does not meet the criteria for May 24, 2023, forward as this enrollee was not shown to be a danger to 
herself or others, auditory or visual hallucinations noted. She was cooperative/compliant with treatment while 
not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve coverage of behavioral health inpatient psychiatric treatment from May 
24, 2023, and forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a permanent pacing cardioverter-
defibrillator system. 
 
You asked the Plan to pre-approve the insertion of a permanent pacing cardioverter-defibrillator system. You 
say that the records provided support the need for the requested device.  The Plan denied your request. The 
Plan says the records do not show that the amount of blood the enrollee's left lower heart chamber pumps with 
each beat of the heart is 35% or less. The Pan says that the records do not show that the enrollee has had a full 
three months of the treatment that research has shown to have the most success for their type of problem.  
 
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 insertion of a permanent pacing 
cardioverter-defibrillator system. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case.  Our physician reviewer found review of clinical documents 
does not show that the patient meets implant criteria for defibrillator insertion according to current guidelines. 
In the absence of such documentation, implantation of an automatic defibrillator would not be considered 
medically necessary in the management of this patient. 
 
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 insertion of a permanent pacing cardioverter-defibrillator system have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a permanent pacing 
cardioverter-defibrillator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 services. 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 imaging study showing only modic endplate changes without foraminal stenosis or 
facet degenerative joint disease (DJD). The cause of back pain is not clear. 
 
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 intracept procedure (64628 and 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108). 
 
You asked the Plan to pre-approve a transit system. You say that due to the enrollee's medical condition, the 
requested equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says a 
transit system does not primarily serve a medical purpose, since the wheelchair is for in-home use and not for 
use out of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  Therefore, we decided that the Plan does 
not have to pre-approve a transit system (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion exploration, cervical cage, unspecified 
instrumentation and unspecified allograft (22830, 22845, 20930 and 22853). 
 
You asked the Plan to pre-approve spinal fusion exploration, cervical cage, unspecified instrumentation and 
unspecified allograft. You say that the services are necessary. The Plan denied your request. The Plan says 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 spinal fusion exploration, cervical cage, 
unspecified instrumentation and unspecified allograft. 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 
documentation of a recent trial and failure or physical therapy. There is no correlation between exam findings and imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion exploration, cervical cage, unspecified instrumentation and 
unspecified allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve 
spinal fusion exploration, cervical cage, unspecified instrumentation and unspecified allograft (22830, 22845, 
20930 and 22853).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (62321). 
 
You asked the Plan to pre-approve a steroid injection. You say that the requested steroid injection is medically 
necessary. The Plan denied your request. The Plan says that no more than four injections per section of the 
spine can be performed in a 12-month period. 
 
The Plan must follow Medicare rules. Medicare rules say that ESIs are limited to a maximum of four sessions 
per spinal region in a 12-month period. 
 
The medical records show that the enrollee received cervical epidural steroid injections on August 29, 2022, 
October 10, 2022, November 4, 2022, and February 15, 2023. Therefore, we decided that the Plan does not 
have to pre-approve a cervical epidural steroid injection (62321).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing care. 
 You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation does not specify any acute medical concern, change in medications or change in 
treatment plan. The clinical documentation shows that the enrollees vitals were stable, and the wound was 
improving at the last skilled nursing assessment thus further home health skilled nursing would not be 
medically necessary. The records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve robotic radical prostatectomy service with an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON robotic radical prostatectomy. You say that the OON facility has 
the first largest series of performed robotic prostatectomies worldwide, with published outcomes. You say that 
the Da Vinci Surgical System facilitates the surgeon's laparoscopic technique to obtain enhanced patient care 
outcomes that are not routinely achieved with the open and/or un-aided conventional laparoscopic approaches 
to prostatectomy.  The Plan denied your request. The Plan says there are contracted urology providers the 
enrollee can see for treatment.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for 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 pre-approve the OON robotic radical prostatectomy. 
Our reviewer says that the criteria for OON coverage have not been met. Our physician reviewer found the 
Plans denial is medically justified on the basis that it is offering adequate care to meet the enrollees medical 
needs through referral to a contracted urology provider. There is nothing unique about the enrollee's condition 
that that would make it medically necessary for him to see the requested out-of-network provider. The Plan has 
shown that they have in-network providers who meet the Standards of Care required for treatment of the 
enrollee's 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 the OON robotic radical prostatectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve robotic radical prostatectomy service with an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95955, 95937, 95927, 95908) provided on 
March 17, 2021. 
 
You asked the Plan to pay for the services. 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 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 95955, 
95937, and 95927, is not supported by the records provided. Our reviewer found that for code 95955, the 
provided records document electroencephalogram (EEG) monitoring, but do not document EEG diagnostic 
testing as with carotid surgery required by code 95955. For code 95937, the provided records do not document 
repetitive stimulation, paired stimuli, each nerve, as required by code 95937. For code 95927, the provided 
records do not document short-latency somatosensory evoked potential study, stimulation of any/all peripheral 
nerves or skin sites, recording from the central nervous system; in the trunk or head, as required by code 95927. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95955, 95937, and 95927, have not been met. 
 
In this case, we have confirmed that code 95908 is a column II code to column I code 95861 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (95955, 
95937, 95927, 95908) provided on March 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary for 
the enrollee to avoid complications from their chronic medical conditions. The Plan denied your request. The 
Plan says the services are 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 the enrollee's 
condition. Our physician reviewer found the member is a female with a past medical history including 
Parkinson's disease and fibromyalgia who has been receiving occupational therapy since April 4, 2023, in order 
to improve her grip and prevent contractures. There is no documentation to indicate the member has had a 
significant improvement in function with prior therapy. The member or her caregivers should be independent 
with a home exercise program. 
 
The member has previously been treated with outpatient therapies and should be independent with a home 
exercise program. There is no documentation of a recent injury or decline in function. The additional therapy 
services are not an appropriate duration and frequency for treatment of the members medical condition and 
therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional occupational therapy (OT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 2 power wheelchair (PWC) K0843 and 
accessories. 
 
You asked the Plan to pre-approve a group 2 power wheelchair and accessories. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a Group 2 Multiple Power Option PWC is provided 
and criterion is not met, it will be denied as not reasonable and necessary. If the PWC base is not covered, then 
related accessories will be denied. 
 
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 2 power wheelchair and 
accessories. Our reviewer says that the enrollee does not need this item. Our physician reviewer found the 
documentation does not support the member is unable to accomplish mobility-related self-care tasks with an 
alternative assistive device. 
 
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 2 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 power wheelchair (PWC) K0843 and accessories.