Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardiacMEMS implant. 
 
You asked the Plan to pre-approve CardiacMEMS implant. You say that this procedure will provide an 
invaluable diagnostic tool. You say that this procedure has been approved by the Food and Drug administration 
since 2014. You also say that this procedure would reduce the enrollee's hospitalizations. 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 CardiacMEMS implant. Our reviewer 
says that the requested CardiacMEMS implant is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested procedure is considered experimental at this time. Therefore, 
the reviewer found that the requested 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 CardiacMEMS implant have not been met. 
  
 
 Therefore, we decided that the Plan does not have to pre-approve CardiacMEMS implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for sacroiliac joint 
(64625). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee has persistent and severe sacroiliac joint 
pain with significant functional limitations. You also say that the enrollee has undergone two previous 
injections which helped their pain tremendously. The Plan denied your request. The Plan says the requested 
RFA 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 the RFA. Our reviewer says that the 
requested RFA for sacroiliac joint is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested RFA is considered experimental. Therefore, the reviewer found that the 
requested RFA for sacroiliac joint 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) for sacroiliac joint (64625).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee requires further physical therapy 
to address current impairments. You say that the enrollee's needs therapy to return to previous levels of 
function. The Plan denied your request. The Plan says an additional 4 physical therapy visits are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has previously been treated with outpatient therapies 
and should be independent with a home exercise program. The enrollee has no recent injury or a decline in 
function. The additional therapy services are not appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 4 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667)  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the swelling is only in the legs. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesnt support that the enrollee has failed at least 4 weeks of 
conservative care with a basic lymphedema pump.  Additionally, the documentation doesnt support that the 
enrollee has physical findings consisting of truncal, abdominal or chest edema. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual depression screening coded G0444 and the annual 
alcohol misuse screening coded G0442 provided on January 26, 2022. 
 
You asked the Plan to pay for the annual depression screening and the annual alcohol misuse screening. 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. 
 
In this case, the CPT Code Manual definition of code G0444 is annual depression screening, 15 minutes. 
The CPT Code Manual definition of code G0442 is annual alcohol misuse screening, 15 minutes. 
 
 We find that CPT codes G0444 and G0442 are not supported in the medical record. Specifically, there is no 
time documented to meet the criteria for these time-dependent service codes. Based on this information, we 
decided that Medicare rules for coverage of the annual depression screening and the annual alcohol misuse 
screening have not been met. Therefore, we decided that the Plan does not have to pay for the annual 
depression screening coded G0444 and the annual alcohol misuse screening coded G0442 provided on January 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (31600, 43215) provided on September 30, 
2022, and October 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.   
We looked at the file and Medicare rules. Payment for the requested services (31600, 43215) is included in the 
global surgery payment for the procedure (32652) provided on September 16, 2022, which has a 90-day global 
period. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for the services (31600, 43215) provided on 
September 30, 2022, and October 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve lumbar decompression surgery. 
 
You asked the Plan to pre-approve lumbar decompression surgery. You say that lumbar decompression surgery 
is medically necessary. The Plan denied your request. The Plan says that lumbar decompression surgery 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 lumbar decompression surgery. Our 
reviewer says that the requested lumbar decompression surgery is considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic low back pain with radicular 
symptoms. The enrollees imaging shows multi-level degenerative changes. At L4-L5 the enrollee has facet 
hypertrophy and an annular disc bulge with moderate spinal stenosis. A plain film at a different time shows a 
loss of disc height at L5-S1 and degenerative changes. The enrollee had a selective nerve root block at L5 
which was positive. The request is 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 lumbar decompression surgery have been met. Therefore, we decided that the 
Plan has to pre-approve lumbar decompression surgery.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
November 17, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical edema/inflammation and post-surgical lymphedema. You disagree with this denial and believe these 
services were medically necessary and the medical records do support the use. The Plan denied your request. 
The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis 
during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient level of care for a laparoscopy, surgical 
prostatectomy, retropubic radical. 
 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation that the enrollee is at a high anesthetic risk. 
 
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 that the enrollee does not need an inpatient level of care for this request. The records 
do not show that the enrollee has any significant comorbidities that would require inpatient admission. The 
surgical procedure could be performed at an observation 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient level of care for a laparoscopy, surgical prostatectomy, retropubic 
radical.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says the enrollee had a single trial of the 
basic pump performed on the day of a referral for the Flexitouch pump. This does not satisfy the Medicare 
guidelines for the lymphedema pump. Further, it is documented on this day that the member reports that the 
bilateral lower extremity edema is responding well to compression. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and pneumatic appliances (E0656, E0667).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 September 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nplate. 
 
You asked the Plan to pre-approve Nplate. You say that the requested Nplate is medically necessary. The Plan 
denied your request. The Plan says the requested Nplate is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Nplate. Our reviewer says that the 
requested Nplate is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of immune idiopathic thrombocytopenic purpura in the setting of aplastic anemia. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nplate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nplate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology visit with the tertiary care provider. 
 
You asked the Plan to pre-approve the office services. You say that the services are necessary. The Plan denied 
your request. The Plan says a number of equally qualified in-network providers are also available for you to 
seek a second opinion. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 office services. Our physician reviewer found the second opinion can be 
done by an in-network provider. The tertiary care provider is only for your preference. 
 
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 office services have not been met.   
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 the office services. Therefore, we decided that the Plan 
does not have to pre-approve an oncology visit with the tertiary care provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L2, L3, L4, L5 medial branch blocks. 
 
You asked the Plan to pre-approve bilateral L2, L3, L4, L5 medial branch blocks. You say that bilateral L2, L3, 
L4, L5 medial branch blocks are medically necessary. The Plan denied your request. The Plan says the 
requested bilateral L2, L3, L4, L5 medial branch blocks do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 bilateral L2, L3, L4, L5 medial branch 
blocks. Our reviewer says that bilateral L2, L3, L4, L5 medial branch blocks are not medically necessary in this 
case. Our physician reviewer found that only 2 levels may be treated at a time. There needs to be 
documentation that there has been no improvement from physical therapy. The enrollee has radicular 
symptoms which have not been addressed. Facet injections are allowed when there is no other probable source 
of pain. Therefore, the request is deemed not medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral L2, L3, L4, L5 medial branch blocks have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bilateral L2, L3, L4, L5 medial branch blocks.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve the requested services. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says 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 requested services. Our physician 
reviewer found that the enrollee has benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. Treatment with alpha blockers did not help. Prostate artery embolization (PAE) is not indicated or medically 
reasonable and necessary in this case. PAE is considered an experimental technique to treat symptomatic BPH. 
Very limited studies have demonstrated possible short-term safety and efficacy. The most recent guidelines do 
not recommend this procedure outside of a clinical trial setting due to the heterogeneity in the available 
literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular access, 
technical feasibility, higher clinical failure rate compared with more traditional methods (e.g., transurethral 
resection of the prostate [TURP]). 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a prostate artery embolization (PAE).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71275 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code was appropriate for the date 
of service. The Plan denied your request. The Plan says an appropriate diagnosis was not included. 
 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 71275 was billed with diagnosis code I25.84. This diagnosis has a code first note 
indicating this code is never permitted to be used as a primary diagnosis code. 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 procedure code 71275 billed for date of service July 21, 2022.