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 have several medical issues and need assistants. 
You state that cannot be at home by yourself. The Plan denied your request. The Plan says the stay is not 
medically necessary based on SNF criteria. 
 
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 there is no documentation that you require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records support that services in the home with home health care or in a long-
term care facility on a part time basis are appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on December 19, 2022.  
You asked the Plan to pay for the air ambulance service and air mileage. You say that the medical records 
support the medical necessity for the air ambulance transport. The Plan denied your request. The Plan says after 
reassessing the entire clinical situation, the information provided at the time of the appeal does not support 
criteria for fixed wing ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance service and air mileage. 
Our reviewer says that the air ambulance service and air mileage was not medically necessary. Our physician 
reviewer found there is no evidence that all closer facilities were unable to care for (inappropriate services), or 
unable to accept (no beds) the enrollee. As such, transfer to a more distant facility was not shown to be 
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 air ambulance service and air mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one way 
and air mileage provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gauze (A6219) provided on June 20, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the gauze. You say that the enrollee was in an approved skilled nursing facility. 
The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a 
network provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the gauze (A6219) provided on June 20, 2022, by 
an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from March 14, 2023, to March 15, 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 documents do not support this level of care. 
 
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 99223 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 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 the interval histories are not 
detailed.  The medical decision making is not of high complexity.  As such, the billing of CPT 99233 for 
3/14/2023 and 3/15/2023 is not supported. 
 
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 subsequent hospital care (procedure code 99233) rendered from March 14, 2023, to March 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 8, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with he 
copayment. 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 $45 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on December 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 25, 2022, to 
January 8, 2023. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA and 
medical records. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 25, 2022. The NOA was not received by the Plan until May 5, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from December 25, 2022, to January 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracorporeal shock wave involving musculoskeletal 
system (0101T) provided on January 4, 2023, and January 13, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. 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 0101T is extracorporeal shock wave involving 
musculoskeletal system, not otherwise specified. 
 
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 service. Our reviewer found code 0101T, does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient 
documentation to validate that Extracorporeal shock wave involving musculoskeletal system, not otherwise 
specified was the procedure that was performed on January 4, 2023; therefore, this procedure cannot be 
verified.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the extracorporeal shock wave involving musculoskeletal system (0101T) provided on January 
4, 2023, and January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing (87798, 
87481) provided on March 1, 2023.  
 
You asked the Plan to pay for the urine PCR testing. You say that the standard of care for the evaluation of 
urinary incontinence is urinalysis with urine culture and sensitivity. The Plan denied your request. The Plan 
says these tests were done based on the provider's orders.  
 
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 urine PCR testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the standard of care would include a basic urinalysis and urine culture, but not 
molecular testing. This test was 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 urine PCR testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) testing (87798, 87481) provided on March 
1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo system (0266T). 
 
You asked the Plan to pre-approve the system. You say that the Barostim Neo system is medically necessary. 
The Plan denied your request. The Plan says the Barostim Neo system is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollee's clinical 
management.  
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo system (0266T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power wheelchair (K0813).  
 
You asked the Plan to pre-approve the power wheelchair. You say that you have difficulty walking and are 
short of breath when walking long distances.  The Plan denied your request. The Plan says no evidence was 
submitted that you do not have muscle strength to self propel a manual wheelchair, and the Medicare criteria 
have not been met.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our physician 
reviewer found the documentation available for review does not support that you require a power mobility 
device to accomplish mobility related self-care tasks in the home. There is no indication you are unable to use 
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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 standard power wheelchair (K0813).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (POV) with a 
patient weight capacity up to 300 pounds (K0800).  
 
You asked the Plan to pre-approve the POV. You say that you need a scooter to help you get around because 
you are confined to your apartment.  The Plan denied your request. The Plan says based on the clinical 
information provided to us you have difficulty walking but have not had a home evaluation. The Plan also says 
that therefore, this request cannot be authorized at this time.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 POV. Our physician reviewer found the documentation available for review does not support that you require a power mobility device (PMD) to 
accomplish mobility related self-care tasks in the home. There is no indication you are unable to use an 
alternative assistive device. Additionally, the documentation does not include a home assessment that shows 
the requested (PMD) will fit in the home or that you can safely use it. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 1 standard power operated vehicle (POV) with a patient weight capacity up to 300 
pounds (K0800).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on January 16, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for, as it meets medical necessity 
requirements. The Plan denied your request. The Plan says this was downcoded to CPT 99284. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation included an 
expanded problem-focused history and exam which was appropriate; however, the enrollee was stable and did 
not appear to require any complex or high level of decision-making in the emergency department.   
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 emergency room services (procedure code 99285) rendered on January 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show that 
your prostate is greater than 150 milliliters per transrectal ultrasound. You have not had an early detection 
evaluation for prostate cancer that meets National Comprehensive Cancer Network (NCCN) guidelines. 
 
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 service. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
Specifically, the records show that   prostate size is greater than 150 milliliters (241 mL) per transrectal 
ultrasound (Medicare requires a size of 30-150 cubic centimeters (cc) by transrectal ultrasound. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the transurethral waterjet ablation of prostate (0421T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure addresses a treatment 
gap for those suffering from chronic low back pain. You say that the enrollee has tried and failed conservative 
treatment without relief. You also say that the science supporting the safety and effectiveness of the procedure 
is robust. The Plan denied your request. The Plan says the Intercept procedure for the lower back for 
vertebrogenic pain is considered investigational and therefore 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 Intracept procedure. Our reviewer says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. The reviewer found that provided records document facet arthrosis and other 
degenerative changes on spinal imaging which may be the cause of the enrollees back pain. Therefore, the 
reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve the MyoPro. You say that the brace is medically necessary. The Plan denied 
your request. The Plan says the brace is considered experimental and investigational. 
 
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 MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 MyoPro have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro powered arm brace (L8702).