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

 
We decided that the Plan does not have to pay for the outpatient office visit (99211) manual electrical 
stimulation (90732) therapeutic procedure, neuromuscular reeducation (97112) injection, pyridoxine hcl, 100 
mg (J3415) unclassified drugs (J3490) injection of drug/substance under skin or into muscle (96372)   
vasopneumatic device (97016) provided September 11, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you are submitting medical records to prove 
medical necessity. The Plan denied your request. The Plan says the clinical value and effectiveness have not 
been proven for Sanexas neoGen-series therapy, the vasopneumatic device therapy and the injection of FDA 
nutria-pharmaceutical blend. 
 
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. 
 
The office visit at issue was billed with modifier 25, which is used to report a significant, separately 
identifiable Evaluation and Management (EM) service by the same physician or other qualified health care 
professional on the same day of a procedure or other service. There is no documentation of any significant, 
separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. 
Review of the file and publicly available records, we find that the physical therapy services at issue in this case 
were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Ohio. The multiple 
drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that 
any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was 
not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration 
code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of 
the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99211) manual electrical stimulation (90732) therapeutic procedure, neuromuscular 
reeducation (97112) injection, pyridoxine hcl, 100 mg (J3415) unclassified drugs (J3490) injection of 
drug/substance under skin or into muscle (96372)   vasopneumatic device (97016) provided September 11, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test kit received on December 18, 2021. 
 
You asked the Plan to pay for the COVID-19 test kit. You say that you came down with symptoms and needed 
to buy this kit before a family party. The Plan denied your request. The Plan says the item received is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the COVID-19 test kit received on 
December 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 15, 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 the denied code remains 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 26990 is "Incision and drainage, pelvis or hip joint area; 
deep abscess or hematoma." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative note indicated an 
evaluation of the wound found edges to be denuded and necrotic and indication for incision and drainage (I&D) 
excision of the necrotic tissue was made. Incision was marked out and ellipsed, then entire anterior wound 
incision was removed, approximately 6cm x 3cm ellipse wound brought down to the level of the fascia for 
which necrotic fat and skin as well as dermal epidermal layer were discarded. Deep wound was then explored 
and muscle layers as well as fascia was found not to be violated. The deep tissue was noted to not have been 
involved. The incision and drainage were of the necrotic fat and skin, as well as dermal epidermal layer. This 
does not include deep (to fascia) tissue layers.  Therefore, the records do not support CPT 26990- incision and drainage, pelvis or hip joint area; deep abscess 
or hematoma. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on October 11, 
2021, to October 14, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says these services could have been provided under 
observation care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee did not have low blood pressure of bleeding. The enteroscopy that was 
scheduled on 10/12/21 did not occur until 10/13/21. In addition, this test did not have to be performed during 
an inpatient hospital admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on October 11, 2021, to October 14, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blood for lab tests drawn from home (CPT code 36416). 
 
You asked the Plan to pre-approve the services. You say that you are appealing the denial of a lab work done 
by a home health nurse because you are disabled and just got discharged from the hospital where you were 
admitted for pneumonia. You state that you are very weak and cannot get in and out of your spouse's car to be 
driven to the lab. The Plan denied your request. The Plan says the Medicare rules have not been met. 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. This service may be reasonable and 
necessary if you are home bound, and the records sent in do not how you are confined to your home. Therefore, 
we decided that the Plan does not have to pre-approve blood for lab tests drawn from home (CPT code 36416).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on December 8, 2021, to 
December 9, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this stay was medically necessary. The 
Plan denied your request. The Plan says that these services could have been provided under observation care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on December 8, 2021, to December 9, 2021.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis, posterior or posterolateral technique, 
single interspace; lumbar (with lateral transverse technique, when performed) (22912) and a posterior non-
segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial 
transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (22840). 
 
You asked the Plan to pre-approve the requested spinal procedures. You say that the requested procedures are 
medically necessary. The Plan denied your request. The Plan says the requested procedures do not meet 
criteria. 
 
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 spinal procedures. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the FDA states this non-pedicle supplemental fixation device is intended for use at a 
Single Level in the non-cervical spine (T1-S1). You are requesting a 2-level procedure at L3/4 and L4/5. Also, 
the Minuteman G3-R MIS Fusion Plate is intended for use with bone graft material and is not intended for 
stand-alone use. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal procedures have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with 
lateral transverse technique, when performed) (22912) and a posterior non-segmental instrumentation (eg, 
Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, 
sublaminar wiring at C1, facet screw fixation) (22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on December 1, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no 
documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
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. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on December 
1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on February 16, 
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 Current Procedural Terminology (CPT) code 64772-RT (1 Unit) remains 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 64772 is "Transection or avulsion of other spinal nerve, 
extradural." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that detailed documentation is not 
evident regarding any nerves having been transected or avulsed. An incision was made in the right wrist, and 
dissected down through skin and subcutaneous tissues. The third dorsal compartment was released and 
transposed the extensor pollicis longus tendon subcutaneously. The fourth dorsal compartment was opened, and 
a longitudinal capsular incision was made. The synovium was obviously infected, and a synovectomy was 
performed. The scaphoid, lunate, and triquetrum were removed in their entirety. The bases of the index, 
middle, and ring finger metacarpals were debrided. The devitalized tissue was all thoroughly debrided. Therefore, the records do not support that CPT 64772: transection or avulsion of other spinal nerve, extradural- 
was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on December 21, 2021. 
 
You asked the Plan to pay for the CxBladder testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the service at issue is CxBladder 
testing. This is strictly not covered. Based on this information, we decided that Medicare rules for coverage of 
the CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder testing provided on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous device, lumbar 
single level, including guidance for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is an excellent candidate for this 
procedure. The Plan denied your request. The Plan says research has not found this treatment to be helpful. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that interlaminar spacer devices remain experimental for use in spine surgery. 
 
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 insertion of an interlaminar/interspinous device, lumbar single level, including guidance 
for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy for gynecomastia. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this service is cosmetic and not covered. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is documented that the enrollee has never had a workup for gynecomastia. The grading of 
gynecomastia per the American Society of Plastic Surgeons classification is not documented. The 
documentation does not support that the enrollee's gynecomastia persists despite correction of any underlying 
causes, and that hormonal causes have been excluded by appropriate laboratory testing, and that the 
gynecomastia persists after 3 to 4 months of unsuccessful medical treatment, the use of potential gynecomastia-
inducing drugs and substances has been ruled out, and the gynecomastia persists for at least one year. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a mastectomy for gynecomastia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve endovenous ablation therapy. 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 ERFA and laser ablation are covered only for the 
treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have 
failed 3 months of conservative 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 endovenous ablation therapy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found it is not possible to 
attribute the enrollees right leg symptoms to a perforator vein in the presence of peripheral arterial disease 
(PAD) or possible deep vein thrombosis (DVT). Additionally, coverage criteria would require failure of 
conservative efforts to treat the enrollee. There is no documentation of such efforts. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on November 
23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no 
documented contact with the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
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. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on 
November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 ESI will be considered medically reasonable and 
necessary when specific criteria are 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, there is 
no documented radicular pain nor exam showing motor or sensory deficits. The record notes the enrollee had a 
prior spine injection without relief in symptoms. The enrollee's pain appears to be axial in nature. Imaging 
shows significant facet hypertrophy. The review has determined that the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
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 pre-approve an epidural steroid injection.