Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the immune globulin injection rendered on December 28, 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 the services are not covered. 
 
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 has not provided a clear denial reason in the submitted documentation. 
The Plan has not provided any clear documentation or binding Medicare rules to support that the services are 
not covered. Therefore, we decided that the Plan has to pay for the immune globulin injection rendered on 
December 28, 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 the destruction by neurolytic agent, genicular nerve 
branches. 
 
You asked the Plan to pre-approve the destruction by neurolytic agent, genicular nerve branches. You say that 
the service is medically necessary. The Plan denied your request. The Plan says this procedure is considered 
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 destruction by neurolytic agent, 
genicular nerve branches. Our reviewer says that the requested service is not considered medically reasonable 
and necessary in this case. Our physician reviewer found this procedure is considered experimental. 
 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 destruction by neurolytic agent, genicular nerve branches have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the destruction by neurolytic agent, 
genicular nerve branches.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter, a power operated vehicle, group 1 
standard, patient weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve an electric scooter. You say that the requested scooter is medically 
necessary, and you request reconsideration. The Plan denied your request. The Plan says the request is 
considered not medically reasonable and necessary. The records show the enrollee has no documentation of 
being unable to perform ADLs or inability to use her upper extremities. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 electric scooter. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee requires an assistive 
device to ambulate safely. She has pain in her knees and decreased range of motion. Per NCD 280.3, the 
enrollee is able to walk. There is no evidence she requires the scooter to attend to her ADLs in the home. 
 
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 electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electric scooter, a power operated vehicle, group 1 standard, patient weight capacity 
up to and including 300 pounds (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51785, 95861, and 95870 billed for date of 
service September 7, 2022. 
 
You asked the Plan to pay for the billed code. You say that the neuromonitoring was medically necessary. The 
Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 51785 is needle electromyography studies (EMG) of anal 
or urethral sphincter, any technique. The definition of code 95861 is needle electromyography; 2 extremities 
with or without related paraspinal areas. The definition of code 95870 is needle electromyography; limited 
study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic 
paraspinal, cranial nerve supplied muscles, or sphincters. 
 
We find that CPT codes 51785, 95861, and 95870 are not supported and are not separately reportable. Based on 
this information, we decided that Medicare rules for coverage of the billed code have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 51785, 95861, and 95870 billed for date of 
service September 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug, Abaloparatide (Tymlos) pen injector. 
 
You asked the Plan to pre-approve drug, Abaloparatide (Tymlos) pen injector. You say that the enrollee has 
tried and failed Fosamax with worsening bone density. The Plan denied your request. The Plan says this drug is 
on the self-administer drug exclusion list. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve drug, Abaloparatide 
(Tymlos) pen injector.  
 
Benefits for drug, Abaloparatide (Tymlos) pen injector may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says you do not meet the Medicare 
criteria for admission to an IRF. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation 
facility. You can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) surgery. 
 
You asked the Plan to pre-approve PVA surgery. You say that there have been studies describing the utility of 
treating even chronic compression deformities. The Plan denied your request. The Plan says the records show 
the enrollee does not have an acute or subacute osteoporotic vertebral compression fracture. 
 
The Plan follows Medicare rules. Medicare rules state that PVA surgery is only covered if certain inclusion 
criteria are met, and no exclusion 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 PVA surgery. Our reviewer says that 
the enrollee does not meet criteria for PVA surgery. Our physician reviewer found the imaging studies do not 
show a fracture that is less than 6 to 12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (PVA) surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires another 3-4 weeks 
to continue complex respiratory medical care, daily multi-specialty physician follow-up, daily labs, and 
physical/occupational therapy. The Plan denied your request. The Plan says the information we have about 
your condition, you don't meet all the requirements, services can be provided in the current inpatient hospital 
and when ready, to move to another setting in the future. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA disc procedure (0627T). 
 
You asked the Plan to pre-approve VIA disc procedure. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested procedure is 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 VIA disc procedure. Our reviewer says 
that the requested VIA disc procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested VIA Disc procedure 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 VIA disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve VIA disc procedure (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that this is a medical necessity due to the 
enrollee's type 2 diabetes mellitus with hypoglycemia without coma. The Plan denied your request. The Plan 
says although some of the criteria have been met, not all the criteria have been satisfied. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our reviewer 
says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record 
indicates that the enrollee has diabetes mellitus. The record provided does not establish that the enrollee's 
insulin treatment regimen requires frequent adjustment by the enrollee on the basis of blood glucose meters or 
CGM testing results. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, 
spinal applications (E0748). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer 
found you have not failed spinal fusion. You are not undergoing a multiple level spinal fusion. You have not 
failed a spinal fusion. The criteria for the osteogenesis stimulator (E0748) have not been met per L33796. 
 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the test has been extensively validated. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service September 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 billed for September 5, 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 procedure code 76937 is 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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 76937 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with the required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 76937 billed for September 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA for SI joint. You say that you had a lot of relief from this before. You 
also say that you would like to have it done again. The Plan denied your request. The Plan says the requested 
service is 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 RFA for SI joint. Our reviewer says 
that the requested RFA for SI joint is not considered medically reasonable and necessary in this case. Our 
physician reviewer found RFA of the lateral sacral branches is considered experimental/ investigational 
because of the wide variability of efficacy of this procedure reported in the literature. Therefore, the reviewer found that the request RFA for SI joint is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA for SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac (SI) joint.
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 enrollee is to be assessed both medically and 
functionally in regard to premorbid functional capacity to determine whether to benefit from a rehabilitation 
level of care. The Plan denied your request. The Plan says the enrollee's records do not show the need for an 
intensive team for your care, services needed can be provided safely in other settings, a skilled nursing facility, 
home with home health services or home with outpatient therapy. 
 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 there is no indication that the enrollee would require skilled rehabilitation in an 
intensive rehabilitation, under the supervision of a physician with at least 3 visits weekly to regain or maintain 
her functional status. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot be safely discharged and requires 
IRF services to return to their prior level of functioning. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 10, 
2023. 
 You asked the Plan to pay for procedure code 99285. You say that the patient had multiple services on this date 
of service. The Plan denied your request. The Plan says payment for code 99285 is bundled into payment for 
code 99291. 
 
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, we have confirmed that code 99285 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 10, 
2023.