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

 
We decided that the Plan does not have to pay for the knee scooter and sales tax received on January 5, 2022. 
 
You asked the Plan to pay for the knee scooter and sales tax. You say that you broke three toes on your right 
foot and purchased crutches but they were too hard to use. 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 knee scooter and sales tax received 
on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RomTech portable connect adaptive rehabilitation 
device with data capture and remote treatment function device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary for this enrollee's 
rehabilitation treatment. The Plan denied your request. The Plan says an exercise bicycle and therefore a non-
covered item as considered primarily non-medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Exercise equipment is a non-covered item and a non-medical item in nature. Therefore, we decided that the 
Plan does not have to pre-approve RomTech portable connect adaptive rehabilitation device with data capture 
and remote treatment function device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in volume-assured pressure 
support (VAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway pressure 
(BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found there is insufficient documentation to support that you have a neuromuscular disease, thoracic 
restrictive disease, or chronic respiratory failure consequent to COPD. You improved in the hospital with 
BiPAP and oxygen, as well as diuresis and antibiotic therapy. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that you were admitted for surgical repair of a hip fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. In conclusion, there is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically necessary 
procedure. The Plan denied your request. The Plan says this procedure is not proven at this time and remains 
experimental. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Superion spacer is experimental. More research is needed to show safety and 
efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from August 19, 2021, through 
August 24, 2021, at DRG 286. 
 
You asked the Plan to pay for inpatient services at DRG 286. You say that the medical records and clinical 
presentation of the enrollee support the original coding of this claim. You say that removal of secondary 
diagnosis code J96.01 is unjustifiable and the claim should be reinstated at the originally billed DRG. The Plan 
denied your request. The Plan says secondary diagnosis code J96.01 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code J96.01, defined as acute respiratory 
failure, not elsewhere classified Type 2 [with hypercapnia]. 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 inpatient services at DRG 286. Our reviewer says that the documentation does not support 
secondary diagnosis code J96.01. Our physician reviewer found that the enrollee did not require treatment 
consistent with acute respiratory failure. Although the provider documented acute respiratory failure with 
hypoxia, there was no documentation of this in the medical record.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from August 19, 2021, through August 24, 2021, at DRG 286.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 
17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the equipment was issued to the enrollee for 
use during surgery. The Plan denied your request. The Plan says the device is used only for peripheral artery 
disease. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. CMS does not pay any provider or supplier other than the facility for 
services furnished to a beneficiary. The facility must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made with outside providers.  This service was provided via arrangement of the facility. Payment for this service would have been included 
under the facility claim. Payment to you for this service is the responsibility of the facility. 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 pay for the pneumatic compression device provided on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extremity brace (L1843) for the enrollee. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a physical exam showing instability in the knee, or a that there 
has been recent injury or surgery to the knee. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the criteria is evidence of recent surgery, trauma, or chronic instability. None of the criteria for 
medical necessity of the brace are present in the enrollee's condition. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an extremity brace (L1843) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue; by 
radiofrequency generated water vapor thermotherapy (CPT code 53854). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is suffering from urinary retention, 
and they need surgery as soon as possible. The Plan denied your request. The Plan says medical need has not 
been met because the enrollee's records do not show that the enrollee's estimated prostate volume is more than 
30cc and less than 80cc. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiofrequency generated water vapor thermotherapy (53854) is not medically reasonable and 
necessary in this case. The American Urological Association (AUA) Guidelines state that, "Water vapor 
thermal therapy may be offered to patients with lower urinary tract symptoms (LUTS) attributed to benign 
prostatic hyperplasia (BPH) provided prostate volume less than 80gm". In this case the prostate gland is 
165gm. 
 
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 transurethral destruction of prostate tissue; by radiofrequency generated water vapor 
thermotherapy (CPT code 53854).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colo-rectal surgery office visits to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services you need. 
The Plan states they approved a follow-up visit with a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
colo-rectal surgery office visits to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
first 2 vertebral bodies (64628), and thermal destruction of intraosseous basivertebral nerve, each additional 
vertebral body (64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap 
when adequate relief is not achieved with traditional conservative methods. You also say that the enrollee has 
tried and failed conservative treatment without relief. The Plan denied your request. The Plan says the 
requested services are 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Intracept procedure is considered experimental and investigational. 
Therefore, the reviewer found that it is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, first 2 vertebral bodies 
(64628), and thermal destruction of intraosseous basivertebral nerve, each additional vertebral body (64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support the medical necessity due to lack of medical 
complexity and nursing needs, and current level of function for admission to an IRF. While the enrollee would 
benefit from physical therapy (PT) and occupational therapy (OT), the enrollee's rehabilitation needs can be 
safely provided in an alternate and low intensity setting such as in a skilled nursing facility (SNF).  
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve proton beam radiation therapy (PBRT). You say that the requested PBRT is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested proton beam radiation therapy (PBRT). 
 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 proton beam radiation therapy (PBRT). 
Our reviewer says that the enrollee does not meet criteria for the requested proton beam radiation therapy 
(PBRT). Our physician reviewer found the enrollee is with stage cT2cN0M0, Gleason's grade 4+3 
adenocarcinoma of the prostate with baseline PSA of 6.43 ng/mL. Higher levels of precision associated with 
proton beam therapy as compared to other radiation methods are not necessary in this case. Hemorrhoids, 
history of inguinal hernia repair and erectile dysfunction as this enrollee has, do not require the use of PBRT 
rather than traditional radiation treatment. The enrollee does not meet the criteria for the requested proton beam 
radiation therapy (PBRT). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy (PBRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for IRF admission. 
 
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 you do 
not meet criteria for IRF admission. Our physician reviewer found you had tendon release in your wrist. There 
is no other medical event. You had limited walking capacity prior to the day of surgery but you were able to 
walk with supervision. You have not had a significant change in your medical condition or limb function. You do not have change in your neurological status. You do not require complex or intensive rehabilitation. You do 
not require frequent physiatry oversight as there are no complicating factors to your rehabilitation. There is no 
indication for intensive rehabilitation. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services rendered on March 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that procedure code 29881 is not separately payable. 
 
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 states that payment for code 29881 is bundled into payment for code 
29879; however, there are no active procedure-to-procedure (PTP) edits for this code pair. The Plan has not 
provided any documentation or Medicare rules to support that code 29881 is not payable as billed. Therefore, 
we decided that the Plan has to pay for the surgical services rendered on March 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tubal ligation for sterilization. 
 
You asked the Plan to pre-approve tubal ligation. You say that you no longer want to take birth control. The 
Plan denied your request. The Plan says this is not a covered indication. 
 
The Plan must follow Medicare rules. Medicare rules say that sterilization is only covered for the conditions 
established in the applicable NCD.  
 
We looked at the file and Medicare rules. Tubal ligation for sterilization is only covered for the conditions 
stated in NCD 230.3. Sterilization is not covered for the purpose of quitting birth control medication. Based on this information, we decided that Medicare rules for coverage of tubal ligation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve tubal ligation for sterilization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 18, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the 
documentation does not support the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. In this case, there are insufficient medical records to show the billing 
guidelines have been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing 
provided on January 18, 2022.