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

 
We decided that the Plan does not have to pre-approve a lower limb prosthesis vacuum pump. 
 
You asked the Plan to pre-approve a lower limb prosthesis vacuum pump. You say that the enrollee needs a 
prosthesis for the lower portion of her leg in order to walk correctly and also needs a vacuum because the 
prosthetic and vacuum are connected. The Plan denied your request. The Plan says a vacuum-assisted socket 
system does not meet Medicare criteria as 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 a lower limb prosthesis vacuum pump. 
Our reviewer says that a lower limb prosthesis vacuum pump is not considered medically reasonable and 
necessary in this case. Our physician reviewer found vacuum assisted prosthesis in randomized trials has not 
been shown to be superior to prevailing standard prosthesis and is not the standard 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 a lower limb prosthesis vacuum pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower limb prosthesis vacuum pump.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal tract capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that due to a recent transient ischemic attack 
(TIA) in August 2022, elective endoscopy at this time is contraindicated. The Plan denied your request. The 
Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy of the small bowel is 
considered medically reasonable and necessary when the conditions have been 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 a capsule endoscopy. Our reviewer says that a capsule endoscopy is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate the enrollee has had a recent EGD or colonoscopy performed. The reviewer found that the 
documentation does not support absolute contraindication to gastrointestinal (GI) procedures for the enrollee. 
Therefore, the reviewer found that the requested service 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 a capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a gastrointestinal tract capsule endoscopy (91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar arthrodesis surgery (22633, 22842, 22853, 
63052). 
 
You asked the Plan to pre-approve a lumbar arthrodesis surgery. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the 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 a lumbar arthrodesis surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no documentation of smoking status and smoking cessation or no 
updated imaging study in the past 6 months. 
 
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 lumbar arthrodesis surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar arthrodesis surgery (22633, 22842, 22853, 63052).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on August 31, 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 the services are not supported as billed. 
 
The Plan must follow Medicare rules. The rules say that Current Procedural Terminology (CPT) modifier -25 
should only be used on claims for evaluation and management (E/M) services, and only when these services 
are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the 
same day as another procedure or other service. 
 
We looked at the file and Medicare rules. The file shows that the -25 modifier is not supported, as it was not a 
separate procedure from the billed 11900 on the same date of service. 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 the office visit rendered on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
(E0601) provided on April 19, 2022. 
 
You asked the Plan to pay for a CPAP device. You say that the item at issue is a medical necessity for you. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 a CPAP device (E0601) provided on 
April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is not primarily 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. Therefore, we 
decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service January 26, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and are supported as billed. The Plan denied your request. The Plan says this code is included 
in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
August 16, 2022. 
 
You asked the Plan to pay for the CGM supplies. The Plan denied your request. The Plan says the proof of 
delivery does not match the date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The delivery ticket shows that the items were shipped on 
August 2, 2022, and delivered on August 4, 2022. Neither of these dates matches the date of service billed on 
the claim. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies provided on August 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the repeat facet joint injections. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Diagnostic injections or Medial Branch Blocks at the 
same level as a previously successful radiofrequency ablation procedure 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 repeat facet joint injections. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found the request is for 
injections at the same level as a previous radiofrequency ablation procedure. This 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 repeat facet joint injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat facet joint injections (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and accessory 
provided on June 7, 2022. 
 
You asked the Plan to pay for the PCD and accessory. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
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 pay for the pneumatic compression device (PCD) and accessory provided on June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services identified with codes 36466 and 93971 provided on 
July 27, 2022. 
 
You asked the Plan to pay for codes 36466 and 93971. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, the CPT Code Manual definition of code 36466 and 93971 is injection of non-compounded foam 
sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging 
guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous 
vein), same leg. 
 
We find that CPT code 36466 and 93971 is not supported in the medical record. Specifically, the medical 
records submitted do not indicate that injection of a non-compounded foam sclerosant with ultrasound 
compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; 
multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg was 
performed. There is a more appropriate code to be billed for the services provided. 
 
In this case, we have confirmed that code 93971 is a column II code to column I code 36466. Although this 
code was billed with modifier -59, the medical records provided do not show that the service billed with the -59 
modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage of services billed with a -59 modifier have not been met.  
 
Based on this information, we decided that Medicare rules for coverage of codes 36466 and 93971 have not 
been met. Therefore, we decided that the Plan does not have to pay for services identified with codes 36466 
and 93971 provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total disc arthroplasty (artificial disc), anterior 
approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal 
cord decompression and microdissection); single interspace, cervical (22856) and a total disc arthroplasty 
(artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy 
for nerve root or spinal cord decompression and microdissection); second level, cervical (22858). 
 
You asked the Plan to pre-approve total disc procedures. You say that the enrollee is in severe pain and needs 
neck surgery. The Plan denied your request. The Plan says the request does not meet the Medicare or health 
plan coverage 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 a total disc arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found two (2) level cervical disc replacement surgery 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 total disc procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total disc arthroplasty (artificial disc), anterior approach, including discectomy 
with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and 
microdissection); single interspace, cervical (22856) and a total disc arthroplasty (artificial disc), anterior 
approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal 
cord decompression and microdissection); second level, cervical (22858).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is 
considered experimental for the treatment of back pain. More research is needed to support its use. 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 an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection rendered on August 10, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 96372 has an OPPS status indicator of Q1 and 
was billed with revenue code 450, which has a status indicator of V. Payment for code 96372 therefore bundled 
into the facility payment. Therefore, we decided that the Plan does not have to pay for the injection rendered on 
August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75571 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 75571. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 75571 is bundled into payment for 
code 75572. 
 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 75571 
is a column II code to column I code 75572. 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 75571 billed for date of service October 13, 
2022.
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 enrollee would benefit from inpatient rehab to 
improve overall safety and functional mobility prior to returning home with family. The Plan denied your 
request. The Plan says the IRF services you are requesting 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  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. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right knee. The documentation does 
not support that the enrollee has tried and failed Orthovisc OR Supartz FX. The documentation does not 
support that Orthovisc OR Supartz FX would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service July 6, 2022. 
 You asked the Plan to pay for procedure code 11721. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service July 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 3, 2022.