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

We decided that the Plan does not have to pay for a LifeAlert system (A9280) and set up (A9901, S9999) 
provided from June 1, 2020 to July 1, 2020. 
 
You asked the Plan to pay for a LifeAlert system and set up. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Telephone Alert Systems are not covered 
because they are  emergency communications systems and do not serve a diagnostic or therapeutic purpose. 
 
We looked at the file and Medicare rules. The item at issue is excluded from Medicare coverage. Based on this 
information, we decided that Medicare rules for coverage of a LifeAlert system and set up have not been met. 
Therefore, we decided that the Plan does not have to pay for a LifeAlert system (A9280) and set up (A9901, 
S9999) provided from June 1, 2020 to July 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Synvisc One is only covered for certain indications. 
 
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 Synvisc One. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee was evaluated November 18, 2020 for complaints of bilateral knee pain. It was 
stated that the enrollee has received multiple steroid injections in the past; the last one only lasted two days. 
Knee x-rays performed October 18, 2020 revealed Kelgren's stage 3 to 4 changes. Options were discussed 
including anti-inflammatories and physical therapy; the decision was for bilateral Durolane. There is 
insufficient documentation that the enrollee has tried and failed a 3-month trial conservative, non-
pharmacologic therapy prior to the noted visit on November 18, 2020 visit. Therefore, the enrollee does not 
meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT Code 64493). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the requested procedure is supported if your pain is mostly localized to your low back 
and does not travel to other areas of your body. The Plan states the records do not show that you have this type 
of pain. 
 
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 there is evidence that your low back pain is associated with lumbar radiculopathy and neurogenic 
claudication. There is no clear evidence of a 3-month course of comprehensive conservative treatment, 
including physical therapy. There are no current exam findings of facet joint tenderness or positive facet 
loading tests to support the presence of facet joint pain. Therefore, the medical records provided fail to meet the 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
Code 64493).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged evaluation and management service (99358) 
provided on April 28, 2020. 
 
You asked the Plan to pay for the prolonged service. You say that you would like reconsideration because this 
service is for an extended telephone visit. The Plan denied your request. The Plan says the documentation 
provided does not indicate that this provider performed a face-to-face service for the enrollee. 
 
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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
We find that CPT code 99358 is not supported in the medical record. Specifically, the record does not indicate 
that an hour of prolonged services were provided before or after direct patient care on the billed date of service. 
Based on this information, we decided that Medicare rules for coverage of the prolonged service have not been 
met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management 
service (99358) provided on April 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from 
November 28, 2019 to December 3, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. The Plan says that this is an administrative 
determination for coding and is not based on clinical criteria for medical necessity. The plan is upholding the 
claim denial as a valid 61 value code was billed however, a required value code 85 for the county where the 
service was rendered was missing.  
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. The claim submitted has errors in regard to the 
treatment location code reported. Medicare billing criteria are not met. Therefore, we decided that the Plan does 
not have to pay for home health services provided to the enrollee from November 28, 2019 to December 3, 
2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve destruction by neurolytic agent; other peripheral nerve or branch 
(CPT Code 64640). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that the service is not necessary. 
 
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 pre-approve the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found neurolysis for post-herniorraphy pain has been extensively studied and found to be efficacious 
and safe. The procedure is medically reasonable and 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 service have been met. Therefore, we decided that the Plan has to pre-
approve destruction by neurolytic agent; other peripheral nerve or branch (CPT Code 64640).  
 
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 pre-approve Intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
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 pre-approve IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has rectal adenocarcinoma. For this case, the invasion of the sacrum, and 
unresectable disease necessitating very high doses of radiation (with plan to deliver 70 Gy), there is a plausible 
need for IMRT. This represents an exceptional case for which IMRT would be considered to be a standard 
approach as treating this patient without IMRT would result in excessive radiation exposure to normal tissues 
(particularly small bowel). Therefore, the enrollee meets criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity-modulated radiation therapy (IMRT).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 17, 2020. 
 
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 codes 29827, 29828, 29826, and 29822 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code  is 29827 is arthroscopy, shoulder, surgical; with rotator 
cuff repair. The definition of code 29828 is arthroscopy, shoulder, surgical; biceps tenodesis. The definition of 
code 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, 
with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for 
primary procedure). The definition of code 29822 is arthroscopy, shoulder, surgical; debridement, limited. 
 
We find that CPT codes 29827, 29828, 29826, and 29822 not supported in the medical record. Specifically, 
there is no documentation of a shoulder arthroscopy with rotator cuff repair to support code 29827. There is no 
documentation of shoulder arthroscopy with biceps tenodesis to support code 29828. There is no 
documentation of shoulder arthroscopy with surgical decompression of subacromial space with partial 
acromioplasty to support code 29826. There is no documentation of shoulder arthroscopy with limited 
debridement to support code 29822. 
 
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 the surgical services rendered on March 17, 2020.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 above 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require any skilled 
nursing or rehab services on a daily basis at an inpatient level of care. The enrollee does not require skilled 
therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee does not 
require any skilled services on an inpatient basis. The enrollee physical function is at or near her baseline and 
she can receive further 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for 
the enrollee's care and that the enrollee meets the criteria for placement. The Plan denied your request. The 
Plan says rules for LTACH care have not been met. 
 
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 that the enrollee appears to be improving gradually and although requiring additional 
acute care hospital services, the enrollee does not require any services at the LTACH that are not already 
available and covered at the current hospital. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve powered pressure-reducing air mattress. You say that the enrollee is 
bedridden and needs a suitable air mattress to help comfortability and to avoid any additional sores. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the requested service. 
 
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 powered pressure-reducing air mattress. 
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 to support the enrollee has multiple stage II 
pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which 
time the enrollee has been on a comprehensive ulcer treatment program or documentation that supports that the 
enrollee has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis or that the enrollee had a 
myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been 
on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the 
past 30 days. The review has determined that the medical records provided do not meet the requirements li sted 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says your upper 
limb strength and function are adequate to control the approved power options using their own switches. 
 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The documentation shows that a seat elevation system and mossy oak were requested. We looked at the file and 
the rules. Medicare will not pay for equipment that is primarily and customarily used for nonmedical purposes, 
or equipment used for a patients comfort or for the convenience of a person caring for the patient. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a seat elevation system or mossy oak.   
 
The documentation shows that a tubular backrest frame was requested. We looked at the file and the rules. A 
power tilt and recline seating includes: a solid seat platform and a solid back; any frame width and depth. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the requested frame.  
 
The documentation shows that an expandable control system was requested. 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 items. Our physician reviewer found that your left upper limb 
strength is 5 out of 5, and your right upper limb strength is 3 out of 5. You are independent with feeding. 
Although there are 3 approved power options (tile, recline, leg rests), your left upper extremity strength and 
function of independence in feeding  are sufficient for you to control any power options through their own 
individual switches. 
 
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 items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve power wheelchair accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD). 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is only 
covered when provided in a clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when 
provided in a clinical study.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee is enrolled in an approved 
clinical study as required by the above NCD. Based on this information, we decided that Medicare rules for 
coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous image-guided lumbar decompression (PILD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks (64493, 64494). 
 
You asked the Plan to pre-approve facet blocks. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory MBB is considered medically 
reasonable and necessary when specific criteria is met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve facet blocks. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review indicates that the documentation 
provided for review does not have the procedure notes and detailed results for both required diagnostic test 
facet nerve blocks (dual medial branch blocks or MBBs). Detailed results include the percentage and duration 
of pain relief and/or improved function for each test block. The review has determined that the enrollee does 
not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet blocks have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet blocks (64493, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on January 29, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-
network. The Plan says that prior authorization was not obtained. 
 
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 has network providers 
available who can provide 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 outpatient hospital services provided on January 
29, 2020 by an out of network (OON) provider.