Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair with electronic 
connection, harness, expandable controller coded as K0861, E1007, E2620, E1028, E1012, E2607, E2311, 
E2313 and E2377. 
 
You asked the Plan to pre-approve the power wheelchair with upgraded electronics. You say that in view of the 
severity of the enrollee's paralysis of the legs and severe weakness of the upper extremities, please reconsider 
the denial of a power wheelchair. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria as the enrollee is currently able to complete MRADL's safely and effectively using a walker. 
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity.  
 
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 with upgraded 
electronics. 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 a progressive peripheral neuropathy and 
is non ambulatory with recurrent falls. The enrollee does not require a Group 3 power wheelchair per L33789 
as the enrollee has adequate upper body strength to manage standard power drive controls, is not at high risk 
for skin breakdown, does not use intermittent catheterization and does not have spasticity requiring the power 
tilt or recline and tilt. 
 
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 with upgraded electronics have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Group 3 power wheelchair with electronic 
connection, harness, expandable controller coded as K0861, E1007, E2620, E1028, E1012, E2607, E2311, 
E2313 and E2377.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endovenous ablation therapy (36478) and injection 
of non-compounded foam sclerosant with ultrasound compression maneuvers to 
guide dispersion of the injectate (36465). 
 
You asked the Plan to pre-approve the endovenous ablation therapy and injection of non-compounded foam 
sclerosant with ultrasound compression maneuvers to guide dispersion of the injectat. You say that the services 
are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 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 endovenous ablation therapy and 
injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of 
the injectat. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not satisfactorily describe lifestyle limiting symptoms related to the enrollee's varicose 
veins. 
 
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 endovenous ablation therapy and injection of non-compounded foam 
sclerosant with ultrasound compression maneuvers to guide dispersion of the injectat have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the endovenous ablation therapy (36478) and 
injection of non-compounded foam sclerosant with ultrasound compression maneuvers to 
guide dispersion of the injectate (36465).
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 you are requesting an expedited 
reconsideration stating LTACH is the appropriate level of care, and the enrollee is medically stable to be 
transferred to the LTACH at this time. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 improving but still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH 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: 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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in 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 ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for PT services provided from November 16, 
2022, to November 30, 2022. 
 
You asked the Plan to reduce the deductible for PT services. You say that you were already evaluated by the 
referring provider, and you should have had a $40 copayment instead of a deductible. 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. Your 
contract with the Plan says that there is a $550 deductible which applies to PT services.  
 
The item or service you asked the Plan to reduce the deductible for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $550 deductible which applies to PT services. This cost sharing is a contractual obligation that had not 
been met at the time PT services was received on November 16, 2022. Therefore, we decided that the Plan does 
not have to reduce the deductible for PT services provided from November 16, 2022, to November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
provided on October 25, 2022. Additionally, the Plan does not have to waive the copayment applied to the 
chiropractic manipulative treatment (98942) provided on October 25, 2022. 
 
  
You asked the Plan to pay for the extraspinal chiropractic manipulative treatment. Additionally, you asked the 
Plan to waive the copayment applied to the chiropractic manipulative treatment. You say that you are 
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 
extraspinal chiropractic manipulative treatment provided is not a covered benefit. Additionally, the copayment 
has been applied correctly for the in-network Medicare-covered chiropractic visit provided. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 $20 
copayment for each in-network Medicare-covered chiropractic visit. 
 
The records show that the extraspinal chiropractic manipulative treatment provided is not a covered benefit by 
Medicare or the Plan. Additionally, you were asked to pay a $20 copayment for the in-network Medicare-
covered chiropractic visit provided. 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 pay for the extraspinal chiropractic 
manipulative treatment (98943) provided on October 25, 2022. Additionally, the Plan does not have to waive 
the copayment applied to the chiropractic manipulative treatment (98942) provided on October 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on November 18, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting the submitted 
documentation be reviewed. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on November 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our reviewer found that the enrollee has been given a diagnosis of 
Alzheimer's disease, and there is no mention of frontotemporal dementia in the records provided for review, the 
base requirement of the NCD for coverage of this service would not be met. The service cannot otherwise be 
said to be reasonable and necessary for the enrollee 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for September 13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99223 is not supported by the medical records. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit.  
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 these services. Our reviewer says that procedure code 99233 
is not supported by the medical records. Our reviewer found the enrollee was evaluated on September 13, 2022 
prior to cardiac catheterization. The records do not support that there was a comprehensive history and medical 
decision making of high complexity. There is no documentation of a comprehensive examination. Code 99233 
is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99233 billed for September 13, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for fluoroscopic guidance and localization of needle or catheter tip for 
spine or paraspinous diagnostic or therapeutic injection procedures (code 77002) provided on August 4, 2022. 
 
You asked the Plan to pay for fluoroscopic guidance and localization of needle or catheter tip for spine or 
paraspinous diagnostic or therapeutic injection procedures. The Plan denied your request. The Plan says that 
charges for or in connection with services or supplies that are as determined by us to be experimental or 
investigational are excluded from coverage under the member's Plan. 
 
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. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for fluoroscopic guidance and 
localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures 
(code 77002) provided on August 4, 2022.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services rendered on September 7, 2022. 
 
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 that the plan reimburses these codes to anesthesia providers only. 
 
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 has not forwarded a valid denial. The rendering provider is a Certified 
Registered Nurse Anesthetist. Therefore, we decided that the Plan has to pay for anesthesia services rendered 
on September 7, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet intensity of service for acute rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, 51 or greater genes 
(81455) provided November 7, 2022. 
 
You asked the Plan to pay for the Tempus xT testing. You say that this letter and attached documents support 
the medical necessity of the test requested, to assist in the treatment, prognosis, and diagnosis for this type of 
cancer. The Plan denied your request. The Plan says that the requested test is not reasonable and necessary 
because your records do not show that the enrollee has advanced, metastatic, recurrent, and refractory cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Tempus xT testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has advanced metastatic non-small cell lung cancer. The 
review indicates that the medical records provided meet the medically necessary requirements listed in the 
LCD for Medicare coverage. 
 
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 Tempus xT testing have been met. Therefore, we decided that the Plan has 
to pay for the targeted genomic sequence analysis panel, 51 or greater genes (81455) provided November 7, 
2022.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred drugs. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our physician reviewer 
found that the enrollee has osteoarthritis of the left knee. The Plan requires a trial of Monovisc, Orthovisc, 
Synvisc, or Synvisc One before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.