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

 
We decided that the Plan does not have to pre-approve a laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural (63655). 
 
You asked the Plan to pre-approve a laminectomy procedure. You say that the enrollee is in a lot of pain and 
waiting could make it worse with his mobility. The Plan denied your request. The Plan says the request is not 
medically necessary because records show the enrollee has not undergone a psychological evaluation. The 
enrollee's pain has continued to worsen. He has been evaluated by a surgeon and there are no further surgical 
options. The enrollee does not meet the requirements for approval. 
 
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 laminectomy procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found as stated in the NCD 160.7, coverage for an implantation of neurostimulator 
electrodes for chronic pain requires that "Patients have undergone careful screening, evaluation and diagnosis 
by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as 
physical evaluation)." Provided records in this case do not document a psychological evaluation of the enrollee. 
Criteria has not been met for the enrollee. 
 
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 laminectomy procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a laminectomy for implantation of neurostimulator electrodes, plate/paddle, 
epidural (63655).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve the Euflexxa 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 repeat Intra-articular Injections of Hyaluronan are 
covered when significant improvement in knee pain and known improvement in functional capacity resulted 
from the previous series of injections, and; at least 6 months have elapsed since the prior series of injections. 
 
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 Euflexxa injections. Our reviewer 
says that this service is not medically necessary. Our physician reviewer found the enrollee had a 3 injection 
series of viscosupplementation with Hyalgan four months ago. Six months have not elapsed since the previous 
injection. 
 
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 Euflexxa injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Euflexxa injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065 billed for date of service November 
10, 2022. 
 
You asked the Plan to pay for procedure code 77065. You say that the claim was billed correctly and should be 
paid. 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 77065 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 77065 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77065 billed for date of service November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a fixed bridge replacing missing tooth number 30 with a pontic 
(D6245) using teeth numbers 29 and 30 as abutment retainers (D6740). 
 
You asked the Plan to pre-approve the fixed bridge. You say that the bridge and crowns are medically 
necessary due to a failed dental implant (serious gum and bone loss, chronic infection). You say that you have 
been chewing on only one side of your mouth since last fall when the implant was pulled. The Plan denied your 
request. The Plan says that the provider has not submitted any information that supports the need for crowns. 
The Plan says that the provider did not submit any narrative information to show why the requested procedures 
are medically necessary. 
 
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. The Plan covers bridges when 
the services are medically necessary and reasonable. 
 
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 fixed bridge. Our reviewer says that 
the criteria for coverage have been met. Our physician reviewer found the implant crown in area number 30 
failed and was removed. This is the only tooth missing. To provide good bilateral mastication a fixed bridge is 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the fixed bridge have been met. Therefore, we decided that the Plan has to pre-
approve a fixed bridge replacing missing tooth number 30 with a pontic (D6245) using teeth numbers 29 and 
30 as abutment retainers (D6740).  
 
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 pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for a mechanical ventilator set in VAPS mode with Auto-EPAP 
(AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
COPD, obstructive sleep apnea, and obesity hypoventilation syndrome. The enrollee was recently hospitalized 
with pneumonia and ABG was consistent with acute on chronic hypercarbic respiratory failure. The enrollee 
has BiPAP at home, but there is no device download to document compliance with use. There are no 
pulmonary function tests to confirm the diagnosis of COPD and assess severity. If this enrollee has severe 
COPD and chronic CO2 retention, she may benefit from BiPAP with AVAPS during sleep. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 you are medically stable and do not need physician's supervision 3 times a week in an 
IRF. There are no rehabilitation nursing needs identified or documented. At the current level of function, you 
do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with a 
multidisciplinary approach in an IRF. While you may benefit from continued physical therapy, and 
occupational therapy, your rehabilitation needs can be safely provided in a lower intensity and alternate setting. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services 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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or 
equal (L5981), and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968). 
 
You asked the Plan to pre-approve advanced foot with ankle feature. You say that the enrollee reports that the 
current prosthesis is too big. You say that the enrollee's current prosthetic foot is no longer appropriate for their 
daily activities as it is not providing the stability necessary to ambulate safely. The Plan denied your request. 
The Plan says request of new prostheses exceeds the enrollee's functional need and does not meet the Medicare 
criteria of reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that replacement of a prosthesis or prosthetic component 
is covered if the treating practitioner orders a replacement device or part because of a change in physiological 
condition, irreparable wear of the device or a part of the device, or the condition of the device requires repairs 
and the cost of the repairs would be more than 60%of the cost of a replacement device or parts. 
 
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 advanced foot with ankle feature. Our 
reviewer says that the requested advanced foot with ankle feature is not medically necessary. Our physician reviewer found the provided documentation does not support that the enrollee's current K3 system is inadequate 
for the enrollee's needs. Therefore, the reviewer found that the requested advanced foot with ankle feature 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 advanced foot with ankle feature have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or equal (L5981), 
and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biofeedback therapy. 
 
You asked the Plan to pre-approve biofeedback therapy. You say that the enrollee has suffered multiple brain 
injuries and is under the care of a specialist. You say that biofeedback therapy is a beneficial treatment tool for 
someone with cognitive conditions. The Plan denied your request. The Plan says biofeedback therapy has not 
been shown to be useful in the treatment of dementia. 
 
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 biofeedback therapy. Our reviewer says 
that biofeedback therapy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was referred for biofeedback for cognitive deficits. Cognitive deficits are not a 
covered indication for biofeedback therapy. The requested service has not been demonstrated to lead to any 
improvements in dementia. Rather the proposed use of biofeedback in this setting may be better classified as 
being experimental in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of biofeedback therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve biofeedback therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement, forehead, cheeks, 
chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm rendered on October 
13, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 14041 is "Adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 14041 is not supported. 
The documentation does not state that tissue rearrangement was performed with z-plasty zy-plasty, w-plasty, or 
with rotational or advancement flaps. Since these elements are not present, CPT 14041 is not supported.  
We looked at this coder's review, the file, and Medicare rules. 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 adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, 
genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm rendered on October 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the spinal canal 
and contents, lumbar; without contrast material (72148). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. 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 MRIs are covered only when they are 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee has L4-5 
spondylolisthesis, and chronic low back pain. The enrollee has had facet injections, knee replacements,  
leg laser treatments, and physical therapy with a limited benefit. She presented on January 12, 2023 with a 7/10 
low back pain level reported. The physical findings were unremarkable with negative provocative testing, no 
tenderness, normal strength, reflexes, and sensation. An MRI of the lumbar spine was requested. However, no 
red flag diagnosis was described from objective physical examination findings or symptoms. There was no 
planned surgery or other information to support advanced imaging at this time. Therefore, the requested service 
will be considered as not medically necessary based on the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met.  Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the 
spinal canal and contents, lumbar; without contrast material (72148).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on September 6, 2022. 
 
You asked the Plan to pay for UDT for 22 or more drug classes. You say that the treating physician determined 
this test to be medically necessary. The Plan denied your request. The Plan says this testing is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is indicated when 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 pay for UDT for 22 or more drug classes. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that the results of the 
screen were not presumptively positive. The results of the screen were not negative, and this negative finding 
was inconsistent with the enrollees medical history. There was a presumptive test available, locally and/or 
commercially, as may be the case for certain synthetic or semi-synthetic opioids. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of UDT for 22 or more drug classes have not been met. Therefore, we decided that 
the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes (G0483) 
provided on September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are scared you will lose your leg, 
you need LTACH services for more time to save your knee. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care setting. 
 
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 LTACH services.