Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis and posterior non-segmental instrumentation 
with the Minuteman device. 
 
You asked the Plan to pre-approve Minuteman procedure. You say that prior treatments have not been 
successful and this is the best option for the enrollee. The Plan denied your request. The Plan says use of this 
device as a stand-alone procedure has not been shown to be safe and effective. 
 
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 Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Minuteman device is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis and posterior non-segmental instrumentation with the Minuteman 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization 
(37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229). 
 
You asked the Plan to pre-approve the surgical services. You say that you have been blacking out and having to 
go to the hospital. You say that you want to have the ability to walk. You also say that you cannot sleep at night 
and have bad pain. The Plan denied your request. The Plan says that records do not show a blockage of at least 
50% or greater. 
 
The Plan follows Medicare rules. Medicare rules say that peripheral vascular stenting may be indicated for 
patients with symptomatic arterial and venous disease resulting from an occlusive process. 
 
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 surgical services. Our reviewer says 
that the requested surgical services are not medically necessary. Our physician reviewer found the provided 
documentation does not confirm the presence of severe disease. The reviewer found that the documentation 
does not show a blockage of at least 50% or greater by imaging. Therefore, the reviewer found there is 
insufficient documentation to support the medical necessity for lower extremity angiography and 
revascularization in this case. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lower extremity angiography and revascularization (37220, 37221, 37224, 37225, 
37226, 37227, 37228, 37229).
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 LTACH is needed for the enrollee's 
ongoing management of acute care needs. The Plan denied your request. The Plan says the enrollee is receiving 
the care needed in the current hospital and there is no need to transfer to the LTACH at this time. 
 
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 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 the HBOT (99183 and G0277). 
 
You asked the Plan to pre-approve the HBOT. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records show 
the enrollee does not have one of the listed indications for Medicare coverage of hyperbaric oxygen 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 the HBOT. Our physician reviewer 
found the reviewed documentation indicates that the enrollee has a diagnosis of sudden idiopathic hearing loss. 
The record sent by the enrollee's provider indicates that they had a sudden hearing loss in the right ear. The 
enrollee has been treated with steroids with some improvement. The provider is requesting the addition of 
hyperbaric oxygen therapy. The review has determined that the medical records provided did not meet the 
requirements listed in the NCD for Medicare coverage. 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 HBOT have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the HBOT (99183 and G0277).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80069, 83970 and 85027 billed for date of 
service July 21, 2022. 
 
You asked the Plan to pay for procedure codes 80069, 83970 and 85027. You say that the codes submitted are 
covered codes. The Plan denied your request. The Plan says no medical records were provided to support these 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 80069, 83970 and 
85027 have been met. Specifically, no medical records were provided to support that these services were 
medically necessary and were reported correctly. Therefore, we decided that the Plan does not have to pay for 
procedure codes 80069, 83970 and 85027 billed for date of service July 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excess skin removal procedures (abdominoplasty and 
panniculectomy). 
 
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 records show that you had 
significant weight loss after bariatric surgery. The records do not indicate stable weight in the most recent six 
month period or the presence of rashes that have not responded to conservative medical treatment. The records 
do not support that the requested procedures are reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve excess skin removal procedures (abdominoplasty and panniculectomy).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided on July 3, 2021 to August 3, 2021. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that the claim was not billed with a valid diagnosis code. 
 
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. Documentation was not provided to show the diagnosis code that was billed. The 
plan did not cite the criteria used to make the determination. Therefore, we decided that the Plan has to pay for 
home health services provided on July 3, 2021 to August 3, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the use of this drug/regimen is not reasonable and 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 the medication. Our physician reviewer 
found the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis of local recurrence of 
non-small cell lung carcinoma status post combined chemoradiation immunotherapy (durvalumab). The use of 
Keytruda for treatment of local recurrence of non-small cell lung carcinoma status post combined 
chemoradiation immunotherapy (durvalumab) is not supported by one of the major drug compendia, the 
National Comprehensive Cancer Network or by clinical research that appears in a Centers for Medicare & 
Medicaid Services (CMS)-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (CPT code J9271).
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 will benefit from acute inpatient 
rehabilitation and cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says 
the records do not show the enrollee needs an intensive team for care, medically necessary care may be 
provided safely in a different level of care. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array, peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the denial for this procedure is 
unwarranted and unsupported. The Plan denied your request. The Plan says there is insufficient medical 
literature to support the use of the SPRINT PNS system for chronic shoulder pain and the enrollee is not 
enrolled in a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SPRINT PNS system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the percutaneous implantation of neurostimulator electrode array, peripheral nerve (excludes sacral 
nerve) (64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy. 
 
You asked the Plan to pre-approve percutaneous laminotomy/laminectomy. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous laminotomy/laminectomy is only 
covered when the enrollee is enrolled in a clinical study. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee is enrolled in a 
clinical study. Based on this information, we decided that Medicare rules for coverage of percutaneous 
laminotomy/laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous laminotomy/laminectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that there are no trained MyoPro 
providers in or near the enrollee's area. Further, you reviewed the attached list of in-network providers and no 
providers on that list have been trained to provide the MyoPro device at this time. You request reconsideration 
of the denial and permit coverage for this device. The Plan denied your request. The Plan says the enrollee 
must use network providers to get your medical care and services. Service is available in network. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a MyoPro powered arm brace (L8702) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 90833 billed for date of service June 28, 2022. 
 
You asked the Plan to pay for code 90833. The Plan denied your request. The Plan says this is an add-on code. 
 
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 90833 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for code 90833 billed for date of service June 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroiliac joint radiofrequency ablation (64625). 
 
You asked the Plan to pre-approve the sacroiliac joint radiofrequency ablation. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the requested service is not considered 
medically reasonable and necessary in this case. 
 
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 sacroiliac joint radiofrequency 
ablation. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is considered an experimental/ investigational approach because of 
the wide variation in efficacy reported in the literature. 
 
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 sacroiliac joint radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the sacroiliac joint radiofrequency ablation (64625).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim was denied in error. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PBRT (CPT code 77525). 
 
You asked the Plan to pre-approve the PBRT. You say that the enrollee has a favorable intermediate risk 
prostate cancer and believe that the proton therapy is medically necessary for the treatment of the enrollee's 
prostate cancer and should be made available to the enrollee. The Plan denied your request. The Plan says the 
request is not medically necessary. The Plan states a review of the literature indicates that PBRT is not the 
standard of care for prostate cancer and Proton Beam therapy for primary treatment of prostate cancer should 
only be performed within the context of a prospective clinical trial. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the PBRT is not medically reasonable and necessary in this case. 
 
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 PBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the PBRT (CPT code 77525).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (CPT code 93458). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that the enrollee has had a heart 
transplant, or that the enrollee has unstable angina, a large perfusion defect, multiple moderate perfusion 
defects, or left ventricular dysfunction. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a negative radionuclide stress test on December 27, 2022. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would 
not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography, when performed (CPT code 
93458).