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

 
We decided that the Plan does not have to pre-approve a custom prosthetic finger. 
 
You asked the Plan to pre-approve a custom prosthetic finger. You say that this item is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this item would exceed the enrollee's 
needs. 
 
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 custom prosthetic finger. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the custom prosthetic finger made from silicone is not medically necessary 
per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) as the requested device is not 
reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The request exceeds the patient's medical need. The documentation is not clear why 
the patient cannot use a standard non silicone prosthesis. 
 
 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 custom prosthetic finger have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a custom prosthetic finger.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the pneumococcal vaccine you received from an in-network clinic on 
October 26, 2021. 
 
You asked the Plan to pay for the pneumococcal vaccine. You say that the clinic told you that there would be 
no charge for this vaccine and that you had not had one previously. The Plan denied your request. The Plan 
says that pneumococcal vaccines are only covered once per lifetime, and you had already received one in May 
of 2021. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the pneumococcal vaccine by a contract provider. The file does not show that the Plan 
provided notice that the pneumococcal vaccine would not be covered. The Evidence of Coverage does not state 
that pneumococcal vaccines are only covered once per lifetime. Under Medicare rules, this means the 
pneumococcal vaccine is considered approved by the Plan. Therefore, we decided that the Plan has to pay for 
the pneumococcal vaccine you received from an in-network clinic on October 26, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 21, 
2021. 
 
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 an appropriate modifier was not billed in this case. 
 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 76705 
is a column II code to column I code 93976. 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 imaging services provided to the enrollee on October 21, 2021.
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 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. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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: Hospice
Decision: Partially Favorable

 
We decided that the Plan has to pay for the psychiatric hospital care from July 2, 2021, through 
August 7, 2021. We decided that the Plan does not have to pay for psychiatric hospital care provided from  
June 13, 2021, through July 1, 2021. 
 
You asked the Plan to pay for the psychiatric hospital care. You say that you have attached the enrollees 
hospice revocation letter for the Plan to process the claim. The Plan denied your request. The Plan says that 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
We decided that the Plan has to pay for the psychiatric hospital care from July 2, 2021, through 
August 7, 2021.  
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 13, 2021. The dates of service July 2, 2021, through 
August 7, 2021 were not provided before the end of that month. Medicare covers attending physician services 
and all care unrelated to the terminal illness until the first day of the month following the month in which 
hospice was revoked or discharged. Therefore, we decided that the Plan has to pay for the psychiatric hospital 
care from July 2, 2021, through August 7, 2021.  
 
We also decided that the Plan does not have to pay for the psychiatric hospital care provided from  
June 13, 2021, through July 1, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 13, 2021. The dates of service June 13, 2021, through 
July 1, 2021 were provided before the end of that month. Therefore, we decided that the Plan does not have to 
pay for the psychiatric hospital care provided from June 13, 2021, through July 1, 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: 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
currently does not require intensive physician and nursing oversight in an IRF. While you may benefit from 
additional multiple therapies, including physical and occupational therapy, the documentation does not reveal 
that you require this therapy on an intensive IRF level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint nerves. 
 
You asked the Plan to pre-approve the RFA of the SI joint. You say that it is felt that this treatment will provide 
prolonged pain relief. The Plan denied your request. The Plan says there is not sufficient evidence to support 
the use of this treatment. 
 
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 of the SI joint. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Studies completed say that this procedure does not improve outcomes 
compared to standard treatment of SI joint pain. Radiofrequency ablation for denervation, whether performed 
using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 
necessary.  The review has determined that the requested RFA of the SI 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 of the SI joint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, an expandable controller 
harness, and an electronic connection between two or more power seating system motors. 
 
You asked the Plan to pre-approve an expandable controller, an expandable controller harness, and an 
electronic connection between two or more power seating system motors. You say that the records provided 
support the need for the items which remain in dispute. The Plan denied your request. The Plan says although 
there are three approved power options on this wheelchair, there is not a medical need to control these power 
options through the joystick. Documentation shows that the enrollee is able to feed himself. The Plan says that 
the approved power options come with their own switches. 
 
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 an expandable controller, an 
expandable controller harness, and an electronic connection between two or more power seating system 
motors. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation that the requested accessories at issue in this 
case meet Medicare criteria for medically reasonable and necessary. Provided records (a February 16, 2022, 
physical assessment) document that the enrollee has 3/5 bilateral upper extremity (hand and wrist) strength, and 
he has hand and wrist range of motion within functional limits. This indicates the enrollee has adequate upper 
extremity strength and function to operate the wheelchairs power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, an expandable controller harness, and an electronic 
connection between two or more power seating system motors have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller, an expandable controller harness, and an 
electronic connection between two or more power seating system motors.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, a surgical 
procedure done with a needle to repair and strengthen a broken bone in the mid back area, a broken bone in the 
spine in the low back area and a broken bone in the spine (CPT code(s): 22513, 22514, and 22515). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says they require that the enrollee has an approved condition for this procedure, and they 
require that the enrollee has had conservative treatment (physical therapy) for their condition. The Plan states 
the enrollee's doctor did not provide notes that show this; this procedure (kyphoplasty) is not medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the LCD 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, a surgical procedure done with a needle to repair and 
strengthen a broken bone in the mid back area, a broken bone in the spine in the low back area and a broken 
bone in the spine (CPT code(s): 22513, 22514, and 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Purewick System (CPT code E1399 x61). 
 
You asked the Plan to pre-approve the Purewick System. You say that you have been using PureWick catheter 
for 2.5 years due to a large tear inside your bladder. You state you only have three (3) PureWicks left and states 
you use up to two (2) per day because you drink a lot of water with your medication. You state you do not have 
$179 to buy a box of PureWick. The Plan denied your request. The Plan says the Purewick System is not 
medically necessary for your condition. The Plan states the notes submitted do not show that your condition is 
permanent. The Plan states there are appropriate medical items for your care they are: External urine collection 
device metal cup (A4327), and Collection pouch (A4328). 
 
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 Purewick System. Our physician 
reviewer found a Purewick System was requested. The provided records did not sufficiently support the use of 
this device over other less expensive methods. There was no explanation that external urine collection via cup 
and collection pouch would be contraindicated or not possible. Therefore, this you do not meet the LCD criteria 
for Purewick System 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 Purewick System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Purewick System (CPT code E1399 x61).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states that 
physical therapy at a skilled nursing facility may be covered if requested. 
 
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 review has determined that the complexity of the patient's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program.   
There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy evaluation, high-complexity (97163) 
provided September 17, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that the medical records provided support 
the necessity of the services in dispute The Plan denied your request. The Plan says this code is not appropriate 
for the service 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 97163-GP, KX is physical therapy evaluation, high 
complexity, requiring these components: A history of present problem with 3 or more 
personal factors and/or comorbidities that impact the plan of care; An examination of body systems using 
standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with 
unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized 
patient assessment instrument and/or measurable assessment of functional outcome 
 
We find that CPT code 97163-GP, KX is not supported in the medical record. Specifically, the records indicate 
that the service is performed by a physical therapist in a home health or hospice setting. Of note there is an 
appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0151) for the billed service. The 
records show that the Plan had made multiple attempts to obtain additional information from the provider 
without success. Based on this information, we decided that Medicare rules for coverage of the physical 
therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical 
therapy evaluation, high-complexity (97163) provided September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on June 8, 2021. 
 
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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 87379 (mass spectrometry) and G0480 (definitive drug 
testing, 1-7 drug classes). Code 83789 is a column II code with a modifier indicator of 1 when billed with 
column I code G0480. Code 83789 was not billed with an appropriate modifier to allow for separate payment. 
The records do not support the use of the -59 modifier as a separate and distinct procedure service. Therefore, 
we decided that the Plan does not have to pay for the mass spectrometry rendered on June 8, 2021.