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

We decided that the Plan does not have to pre-approve the Intracept procedure (22899). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you strongly believe that the Intracept 
procedure is medically necessary and the most effective treatment for the enrollee at this time. The Plan denied 
your request. The Plan says the Intracept procedure is considered experimental and investigational and is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at 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 the Intracept procedure (22899).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee on July 20, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the member was enrolled in a federal hospice program during the time services were 
rendered. The Plan states the member's services should be billed under Original Medicare and the claim was 
denied for this reason. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The 
member was enrolled in hospice from July 14, 2019, through August 26, 2019. Therefore, we decided that the 
Plan does not have to pay for the services provided to the enrollee on July 20, 2019.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient?s nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using 
the basic pump that Medicare requires. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
 
 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for enterolysis (44005) provided on November 27, 2018. 
 
You asked the Plan to pay for enterolysis. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 
service billed. 
 
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 44005 is enterolysis (freeing of intestinal adhesion) 
(separate procedure). 
 
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 enterolysis. Our reviewer says that CPT code 44005 does not 
meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do 
not include sufficient information to validate that enterolysis (freeing of intestinal adhesion) (separate 
procedure) was performed on November 27, 2018, therefore this service cannot be verified. The procedure 
described in the medical documentation more accurately describes Current Procedural Terminology (CPT) 
code 44180 -Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enterolysis have not been met. Therefore, we decided that the Plan does not 
have to pay for enterolysis (44005) provided on November 27, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis without 
current pathological fracture. She has not tried and failed the Plan's required drug of zoledronic acid. The 
records do not support that the required drug would be contraindicated or less effective; therefore, Prolia is not 
reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30 minute interval (CPT Code G0277). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found the use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of 
healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard 
wound care. Reviewed documentation notes the wound was first evaluated on October 16, 2020. This does not 
support 30 days of conservative treatment was trialed. Without the support of the documentation, medical 
necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30 minute interval (CPT Code 
G0277).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or 
pharmacologic) and/or redistribution and/or rest reinjection (CPT Code 78452). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found the review of submitted documentation does not support the guidelines outlined in the LCD were met. 
You were noted to exercise daily without a problem. Additionally, an electrocardiogram was interpreted 
without noted acute findings or uninterpretable findings. Without the criteria noted in the  guidelines, medical 
necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, 
qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional 
quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or 
redistribution and/or rest reinjection (CPT Code 78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a TENS unit (E0745) provided to the enrollee on May 20, 
2020. 
 
You asked the Plan to pay for the equipment. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a TENS unit (E0745) 
provided to the enrollee on May 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 9, 
2020, to April 7, 2020. 
 
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied 
your request. The Plan says this was custodial care. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that the patient required skilled nursing or therapy services. The records show that the 
enrollee's condition was stable for the dates at issue with no changes in any medical condition or acute 
functional decline. The enrollee did not require services on an inpatient basis in a skilled nursing facility 
setting. 
 
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 pay for skilled nursing facility (SNF) care provided from March 9, 2020, to April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable catheters. 
 
You asked the Plan to pre-approve the catheters. You say that this is medically necessary. The Plan denied your 
request. The Plan says non-reusable, disposable catheters are not a covered benefit under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable equipment is not covered. 
 
The requested catheters are disposable. Based on this information, we decided that Medicare rules for coverage 
of the catheters have not been met. Therefore, we decided that the Plan does not have to pre-approve disposable 
catheters.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6539. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration 
because you have been experiencing leg and foot edema which could be due to circulatory problems. The Plan 
denied your request. The Plan says there is no evidence of a non-healing wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6539 
 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 

Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6539.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build-up. 
 
You asked the Plan to pre-approve core build-up. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build-up.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. 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 medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as 
specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this 
condition and the documentation does not reveal significant objective functional improvement. It does not 
appear that the enrollee requires the unique skills of a professional therapist to safely and effectively provide 
treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. The enrollee has had therapy with repetitive exercises with assist that do not need 
ongoing skilled therapist oversight. The specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to 
prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; 2 views (CPT Code 71046) 
provided on March 12, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says prior authorization was not obtained by the provider or facility. 
 
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 radiologic examination, chest; 2 views (CPT Code 
71046) provided on March 12, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
post-processing under concurrent supervision; not requiring image post-processing on an independent 
workstation (CPT Code 76376) provided on January 15, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Current Procedural Terminology 
(CPT) code 76376 (1 unit) remains not supported. The documentation submitted did not include documentation 
of 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, 
ultrasound, or other tomographic modality with image post-processing under concurrent supervision; not 
requiring image post-processing on an independent workstation; therefore, the billed service cannot be verified. 
It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we 
decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
post-processing under concurrent supervision; not requiring image post-processing on an independent 
workstation (CPT Code 76376) provided on January 15, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on January 17, 
2020. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 76700 is ultrasound, abdominal, real time with image 
documentation; complete. 
 
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 abdominal ultrasound. Our reviewer says that CPT code 
76700 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided do not include sufficient documentation to corroborate an ultrasound, abdominal, real time 
with image documentation; complete was performed on January 17,2020, therefore this service 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 abdominal ultrasound have not been met. Therefore, we decided that the 
Plan does not have to pay for the abdominal ultrasound (76700) provided on January 17, 2020.