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

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has tried and failed physical 
therapy and occupational therapy. Without further intervention, the enrollee will remain without meaningful 
use of their right upper extremity. The Plan denied your request. The Plan says the submitted clinical 
information does not show that this device is 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 orthotic device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the requested device is used for the upper extremity. It is an arm brace 
that is motorized and can help an individual with upper extremity weakness to move their arm and hand. The requested device has not been shown to be superior to other standard treatments for the medical condition. The 
studies do not indicate the MyoPro brace improves an individuals function or general health. The requested 
device is not medically 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 orthotic device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting 
medical records. The Plan denied your request. The Plan says the records do not show at least 3 months of 
conservative measures. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint injections are only covered if certain 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet criteria for the requested facet joint injections. Our physician reviewer found the 
submitted imaging is out of date. The enrollee is medically stable and does not have a documented psychiatric 
disorder. Medicare rules state that an intra-articular injection must be justified by an anatomic limitation which 
is not specified here. 
 
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 joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) of skull base to midthigh for attenuation correction and anatomical 
localization imaging provided on December 27, 2022, billed with procedure code 78815. 
 You asked the Plan to pay for the PET image with CT. You say that the services were medically necessary. The 
Plan denied your request. The Plan says modifier PI or PS is required for codes 78608, 78811, 78812, 78813, 
78814, 78815 and 78816. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. 
 
We looked at the file and Medicare rules. Specifically, the claim has not been billed with the required modifier. 
Based on this information, we decided that Medicare rules for coverage of the PET image with CT have not 
been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) 
with concurrently acquired computed tomography (CT) of skull base to midthigh for attenuation correction and 
anatomical localization imaging provided on December 27, 2022, billed with procedure code 78815.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair parts (E2365, E0973, K0739) provided on 
September 30, 2022. 
 
You asked the Plan to pay for the wheelchair parts. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code E2365, E0973, & K0739 is not supported in the medical record. Specifically, S34.139S 
is a sequela code and not a valid primary diagnosis code. Based on this information, we decided that Medicare 
rules for coverage of the wheelchair parts have not been met. Therefore, we decided that the Plan does not have 
to pay for wheelchair parts (E2365, E0973, K0739) provided on September 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 13, 2022, to 
October 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you provided the NOA and these visits 
were approved. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 13, 2022. The NOA was not received by the Plan until 
November 11, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
services provided from September 13, 2022, to October 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS) (L8680, 
64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that the denial for this procedure is unwarranted 
and unsupported by the enrollee's current medical status and published data. The Plan denied your request. The 
Plan says currently, implantable peripheral nerve stimulators for chronic pain are still being studied to see if 
this treatment is reasonable and 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 Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the enrollee has a diagnosis of fibromyalgia, pain in total body and radiates into both arms, legs, shoulders, hips, and feet. Peripheral nerve stimulation (PNS) may 
be covered for relief of chronic intractable pain for patients with conditions known to be responsive to this 
form of therapy, and only after attempts to cure the underlying conditions and appropriate attempts at 
medication management, physical therapy, psychological therapy and other less invasive interventional 
treatments. As with spinal nerve stimulations (spinal cord stimulators (SCS) are dealt with in a companion 
policy), severe neuropathic pain is typically well suited for successful responses to PNS. There may be rare, 
selected situations where both spinal cord stimulators and peripheral neurostimulators are used together. 
Currently, implantable peripheral nerve stimulators for chronic pain are still being studied to see if this 
treatment is reasonable and necessary. Overall, there is lack of evidence to support PNS over traditional 
treatment of chronic low back pain. There is a lack of literature evaluating long-term efficacy and adverse 
events associated with implantable PNS devices. The review has determined that the items/services at issue in 
this case are 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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint peripheral nerve stimulator (PNS) (L8680, 64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve angle adjustable stroller handles (E0108). 
 
You asked the Plan to pre-approve angle adjustable stroller handles. You say that the requested components are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested item is 
primarily for convenience of the caregiver while pushing the enrollee primarily outdoors. The Plan also says 
this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve angle adjustable stroller handles (E0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration 
(D9610). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee needs to have the requested 
services and you do not agree with the down code. The Plan denied your request. The Plan says this service is 
not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Therapeutic parenteral drug, 
single administration (D9610) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9610 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve therapeutic 
parenteral drug, single administration (D9610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient clinic services provided on May 12, 2022. 
 
You asked the Plan to pay for the outpatient clinic services. You say that the billed services are covered under 
Medicare and you believe you are a network provider. The Plan denied your request. The Plan says you have 
provided insufficient information regarding this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient clinic services have been 
met. Specifically, you have provided no medical records for the services in dispute, despite multiple requests 
from the Plan for this information.  Without records, we cannot determine if the services were medically 
necessary, billed correctly, or covered under the patient's medical benefits. Therefore, we decided that the Plan 
does not have to pay for outpatient clinic services provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service November 
26, 2022. 
 You asked the Plan to pay for procedure code 86077. You say that the medical records show the medical 
necessity of this service. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service November 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vagus nerve stimulation (VNS). 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that VNS are covered 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee had a stroke with left upper extremity sensory and motor deficits. This is not a condition for which VNS is covered by the Medicare rules. 
The current peer-reviewed stroke guidelines do not document that the use of VNS has been shown in controlled 
studies to result in long-term health benefits with patients with upper extremity sensory and motor deficits. The 
services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vagus nerve stimulation (VNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary.

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 a home ventilator. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found
that the provided primary-source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. The Plan has indicated coverage for such a device is available upon request.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
January 25, 2022, to January 26, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 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 is a 59-year-old with End Stage Renal Disease (ESRD) on dialysis and a 
history of peptic ulcer disease who presented to the emergency department (ED) with indigestion symptoms 
since the loss of his son. He had been taking Carafate. The workup was essentially noncontributory except for 
hemoglobin (Hgb) was 8.7 without signs of active bleeding. The enrollee was treated with a gastrointestinal 
(GI) cocktail. The enrollee was instructed to follow-up for dialysis as outpatient. Based on the stability of the 
enrollee and uncomplicated treatment, it was not expected that the enrollee would require hospital care that 
would likely cross two midnights.  
 
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 from January 25, 2022, to 
January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets medical necessity for admission to 
the IRF. The Plan denied your request. The Plan says based on Medicare guidelines, IRF services requested do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. There is not a reasonable expectation that 
the enrollee 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. 
 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. 
 
We looked at the file and the rules. A heavy-duty wheelchair and related accessories were requested. The 
records provided do not show that the enrollee weighs more than 300 pounds, therefore, not meeting the 
criteria. If the manual wheelchair base is not covered, then related accessories will be denied as not reasonable 
and necessary. Furthermore, the requested provider in this case is not a network provider with the Plan. The 
Plan has network providers available who can provide the services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does 
not have to pre-approve an extra heavy-duty wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve high-intensity focused ultrasound (HIFU) ablation of malignant 
prostate tissue. 
 
You asked the Plan to pre-approve HIFU. You say that HIFU is the most medically appropriate and reasonable 
treatment option. The Plan denied your request. The Plan says that this is 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 HIFU. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found HIFU treatment of the prostate is neither experimental nor investigational. HIFU was Food & 
Drug Administration (FDA) approved for prostate gland ablation and has Medicare coverage. Numerous 
clinical studies have demonstrated treatment efficacy that is comparable to surgery or radiation, but with a 
much lower risk of side effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU have been met. Therefore, we decided that the Plan has to pre-approve 
high-intensity focused ultrasound (HIFU) ablation of malignant prostate tissue.  
 
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.