Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that the treatment is medically necessary. The Plan denied 
your request. The Plan says there is not enough evidence that this type of radiation therapy guidance is needed 
or effective for the enrollee's skin cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that usually, IGRT is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to this enrollee for which the target 
lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need 
for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not 
unreasonable to offer but not necessary. The device itself is Food and Drug Administration (FDA) approved for 
use with ultrasound though that in and of itself does not mean that daily imaging is necessary but simply that 
the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280- 
also requested in this case) and/or IGRT for a technology for which need has not been established by published 
data or supported by consensus guidelines (many of which recommend against treatment with these devices in 
general) is not necessary. The decision is unfavorable as billing for daily IGRT which would not be furnished 
in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation therapy (IGRT) (G6001).
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 the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the IRF services requested do not meet the requirements for 
approval.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is 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, but the services required can be provided at a lower level of 
care.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve reinstate vision benefits. 
 
You asked the Plan to pre-approve reinstate vision benefits. You say that you want the enrollee's vision benefits 
to be reinstated because the first eye examination was done incorrectly. The Plan denied your request. The Plan 
says that the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit the medical records for the May 24, 2023, date of 
service. This means we cannot determine if the enrollee's vision benefits have been exhausted. Therefore, we 
decided that the Plan has to pre-approve reinstate vision benefits. 
  
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: 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 SNF care is medically necessary. The Plan denied 
your request. The Plan says the requirements for coverage of SNF care have not been met. 
 
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 the enrollee does not require skilled nursing and/or skilled therapy services on a daily 
basis. She is medically stable and can receive further rehabilitation services at a lower level of care.  Although 
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent 
skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not 
have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically 
stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her 
baseline and she can receive services at a lower level of care. 
 
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 pay for a double upright thigh and calf knee orthosis with adjustable 
flexion and extension joint, medial lateral and rotation control (L1852) and a suspension sleeve addition to the 
lower extremity orthosis (L2397) provided on June 26, 2023. 
 You asked the Plan to pay for the knee orthosis and suspension sleeve addition. You say that the records 
provided support the need for the items in dispute. The Plan denied your request. The Plan says the records do 
not demonstrate any indication that the requested brace is needed. The records indicate that the enrollee's knee 
had visual arthritic changes, but it was not specifically evaluated by examination or with radiologic imaging. 
There was also no indication that was concern for knee instability on exam.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that the knee orthoses represented by code L1852 are only 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s), or if the enrollee is 
ambulatory and has knee instability. 
 
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 knee orthosis and suspension sleeve 
addition. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has arthritis. There is no evidence of a recent injury or 
surgery. There is no evidence of instability. 
 
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 knee orthosis and suspension sleeve addition have not been met. Therefore, 
we decided that the Plan does not have to pay for a double upright thigh and calf knee orthosis with adjustable 
flexion and extension joint, medial lateral and rotation control (L1852) and a suspension sleeve addition to the 
lower extremity orthosis (L2397) provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a wheelchair (K0739x9), a foam caster tire 
(E2389x2), caster wheel excludes tire (E2395x2), foam filled drive wheel tire (E2386x2), drive wheel excludes 
tire (E2394x2), a solid (rubber/plastic) caster tire with integrated wheel (E2392x2), a caster axle kit (K0108x4) 
and an arm pad replacement (K0019x2). 
 
You asked the Plan to pre-approve repairs to a wheelchair and accessories. You say that the enrollee is a 
quadriplegic that requires the use of his complex power wheelchair which was purchased by Medicare 
February 28, 2019. The Plan denied your request. The Plan says Medicare does not cover repairs when the 
expense for repairs exceeds the estimated expense for replacement of the wheelchair. 
 The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The case file shows that the existing equipment is less than 5 years old. Specifically, repairs cannot be covered 
if the cost of repair is more than the cost of replacement. This means that replacement of this equipment due to 
wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-approve repairs to a 
wheelchair (K0739x9), a foam caster tire (E2389x2), caster wheel excludes tire (E2395x2), foam filled drive 
wheel tire (E2386x2), drive wheel excludes tire (E2394x2), a solid (rubber/plastic) caster tire with integrated 
wheel (E2392x2), a caster axle kit (K0108x4) and an arm pad replacement (K0019x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the records provided support the need for the drug in 
dispute. The Plan denied your request. The Plan says Opdivo is not medically necessary for the enrollee at this 
time. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of 
metastatic esophageal adenocarcinoma. The FDA has not stated that the requested drug is indicated as prescribed for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's specific clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The documentation does not support that 
the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (procedure code 99214) 
performed on June 21, 2023. 
 
You asked the Plan to pay for an office or other outpatient visit (procedure code 99214). You say that 
procedure code 99214 is appropriate based on the level of services required. The Plan denied your request. The 
Plan says procedure code 99213 is more appropriate for the services rendered. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
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 an office or other outpatient visit (procedure code 99214). 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
reviewer found that the documentation does not support this level of billing either by degree of complexity or 
by time. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office or other outpatient visit (procedure code 99214) have not been met. 
Therefore, we decided that the Plan does not have to pay for an office or other outpatient visit (procedure code 
99214) performed on June 21, 2023.
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 continued SNF care is medically necessary. The 
Plan denied your request. The Plan says the requirements for approval of SNF care have not been met. 
 
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 the enrollee was at stand-by assist for transfers, ambulation, and stairs. The enrollee 
is able to continue with repetitive exercise and does not require continued daily skilled therapy. She does not 
have daily skilled nursing needs. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (procedure 99214) 
performed on June 24, 2023. 
 
You asked the Plan to pay for an office or other outpatient visit (procedure 99214). You say that procedure 
code 99214 is appropriate based on the level of services required. The Plan denied your request. The Plan says 
procedure code 99213 is more appropriate for the services rendered. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
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 an office or other outpatient visit (procedure 99214). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found the documentation do not support this level of billing either by degree of complexity or by time. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office or other outpatient visit (procedure 99214) have not been met. 
Therefore, we decided that the Plan does not have to pay for an office or other outpatient visit (procedure 
99214) performed on June 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiotherapy (SBRT) services. 
 
You asked the Plan to pre-approve the SBRT services. You say that SBRT is the recommended, most 
conservative treatment for metastatic large cell neuroendocrine carcinoma, according to the National 
Comprehensive Cancer Network (NCCN) guidelines. The Plan denied your request. The Plan says there is no 
good evidence the SBRT treatment is safe or effective for the enrollee's cancer. The Plan says that SBRT 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 SBRT services. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found , in the absence of adequate and standard treatment of primary disease (lung mass and mediastinal lymphadenopathy), SBRT to a lung mass alone and SBRT to an adrenal lesion is not considered 
standard treatment. If SBRT to an adrenal lesion is considered, the primary site should also be treated 
adequately with curative intent (if possible). SBRT to a lung mass in this case is not considered curative and is 
not enough to address the primary. If SBRT to a lung mass and an adrenal lesion is considered in the setting of 
stage IV disease with oligometastasis, it is typically considered in the case of oligoprogressive or 
oligopersistent disease following systemic therapy. Therefore, neither SBRT to the right lung mass nor SBRT 
to the left adrenal lesion is medically reasonable and necessary 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 the SBRT services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve stereotactic body radiotherapy (SBRT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1852) and a suspension sleeve (L2397) 
provided on June 28, 2023. 
 
You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the request is not 
medically necessary because the records do not demonstrate any indication that the requested brace is needed. 
 
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 a knee orthosis and a suspension sleeve. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a knee orthosis (L1852) and suspension sleeve (L2397) are not medically 
necessary per the Local Coverage Determination (LCD) L33318. The enrollee is ambulatory, but the 
documentation does not reveal evidence of right knee objective joint laxity or instability on a physical 
examination. There is no evidence of a recent injury or surgery to the right knee. 
 
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 knee orthosis and a suspension sleeve have not been met. Therefore, we 
decided that the Plan does not have to pay for a knee orthosis (L1852) and a suspension sleeve (L2397) 
provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural steroid injection (62322) provided on April 26, 
2023. 
 
You asked the Plan to pay for an epidural steroid injection. You say that the claim should be reprocessed. The 
Plan denied your request. The Plan says the epidural steroid injection 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 pay for an epidural steroid injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had abdominal surgery under general anesthesia and also had a spinal 
anesthetic administered for post-operative pain control. This is a miscoding issue. The code as billed is not 
supported. 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pay for an epidural steroid injection (62322) provided on April 26, 2023.