Persius/hicric huggingface dataset:
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 you are appealing, on behalf of the enrollee, the pre-
service denial of services in an inpatient rehabilitation facility. The Plan denied your request. The Plan says 
admission to acute inpatient rehabilitation was denied as not meeting criteria, is not medically necessary, and a 
lower level of care might be appropriate. Skilled nursing facility level of care was offered. 
 
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 was admitted for pulmonary embolism, urinary tract infection, and 
rhabdomyolysis. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the 
enrollee has a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 13, 2021, to 
August 17, 2021. 
 
You asked the Plan to pay for the home health services. You say that you follow the policy and procedures for 
this claim to be processed. The Plan denied your request. The Plan says no exception request was received to 
waive the 5-day requirement for filing the RAP claim due to a circumstance beyond your control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, July 13, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from July 13, 2021, to August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Dexcom CGM. You say that you need the Dexcom CGM because your 
blood sugar goes up and down frequently and you would like real-time results. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. There is no evidence you have tried the Plan's formulary (list of covered 
drugs) alternative, Freestyle Libre. 
 
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 Dexcom continuous glucose monitor (CGM) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of chronic low back pain due to degenerative disc disease, vertebrogenic pain, and Modic type 
changes has not been demonstrated in the peer-reviewed literature. 
 
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 requested services are not considered medically reasonable and necessary in this case. There are multiple 
plausible pathologic sources of significant pain generation. The noted pain-aggravating and pain-relieving 
factors, along with intact neurologic exam are all non-specific to any pathologic entities. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks (64454). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says medical-necessity rules for coverage have not 
been met because the requested services are experimental/investigational. 
 
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 genicular nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is considered experimental/investigational. Its role in the 
therapy of osteoarthritis of the knee is still being evaluated. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds of the face, ears, 
eyelids, nose, lips and/or mucous membranes represented by code 12014 and billed for date of service February 
2, 2022. 
 
You asked the Plan to pay for code 12014. You say that the documentation provided supports the services in 
dispute. The Plan denied your request. The Plan says the surgical procedure provided November 29, 2021, has 
a global surgery period of 90 days, which had not yet passed at the time of the service in dispute was rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that a modifier of -79 reports an unrelated procedure 
by the same physician during a postoperative period. 
 
We looked at the file and Medicare rules. The records show that the enrollee had a surgical procedure provided 
on November 29, 2021, by a provider of the same specialty and with the same Tax ID as the provider who 
billed the services in dispute. We can see that this surgery was related to the closed treatment of proximal humeral (surgical or anatomical neck) fracture. If the services in dispute were unrelated to this surgical 
procedure, the code should have been billed using a -79 modifier. Because they were not, we decided that 
Medicare rules for coverage of code 12014 have not been met. Therefore, we decided that the Plan does not 
have to pay for the simple repair of superficial wounds of the face, ears, eyelids, nose, lips and/or mucous 
membranes represented by code 12014 and billed for date of service February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization of 
bilateral iliac arteries (37229, 36246). 
 
You asked the Plan to pre-approve lower extremity angiography and revascularization of bilateral iliac arteries. 
You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The 
Plan says medical-necessity rules for coverage of the requested services have not been met. 
 
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 lower extremity angiography and 
revascularization of bilateral iliac arteries. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found that, while the 
enrollee has a history of peripheral vascular disease, the non-invasive studies provided are not consistent with 
severe disease. There is insufficient documentation to support the medical necessity for lower extremity 
angiography and revascularization of bilateral iliac arteries in the enrollee's 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 lower extremity angiography and revascularization of bilateral iliac arteries 
have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity 
angiography and revascularization of bilateral iliac arteries (37229, 36246).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wall-hugger recliner chair. 
 
You asked the Plan to pre-approve these services. You say that you need the chair to assist in standing from a 
sitting position and sleeping. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. While Medicare 
may cover a seat lift mechanism on its own if medically necessary, the recliner chair portion is not covered. 
Therefore, we decided that the Plan does not have to pre-approve a wall-hugger recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 12, 2022 by an out-of-
network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on January 12, 2022 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the closed treatment of distal fibular fracture (27788) billed 
on October 30, 2021. 
 
You asked the Plan to pay for the closed treatment of distal fibular fracture (27788). You say that the medical 
records state the enrollee was seen in the emergency room by the physician for a medically necessary 
procedure. You say that the claim should be reprocessed to pay this procedure code. The Plan denied your 
request. The Plan says the medical records do not support procedure code 27788. 
 
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 27788 is closed treatment of distal fibular fracture (lateral 
malleolus); with manipulation. 
  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 closed treatment of distal fibular fracture (27788). Our 
reviewer says that the medical records do not support procedure code 27788. Our reviewer found that the 
medical documentation from the emergency room provider do not support a fracture repair. The enrollee was 
discharged to follow up with orthopedics. 
 
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 closed treatment of distal fibular fracture (27788) have not been met. 
Therefore, we decided that the Plan does not have to pay for the closed treatment of distal fibular fracture 
(27788) billed on October 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS system for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this service is not covered under Medicare outside of the Medicare 
Coverage Related to Investigational Device Exemption (IDE) Studies process. 
 
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 requested services are not considered medically reasonable and necessary in this case. There remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 the CardioMEMS system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections 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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that in this case, the 
enrollee had successful radiofrequency ablation (RFA) procedures in January of 2022 and December of 2021, 
at the same spinal levels as the current request. The records do not specify why diagnostic procedures are being 
requested as opposed to repeat RFA procedures. The review has determined that the requested facet joint 
injections do not meet the Medicare LCD coverage criteria. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. The 
complexity of your nursing medical and rehabilitation needs do not require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. You do not require rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, tracheostomy management or bowel and bladder 
management. Your medical and rehabilitation needs do not require the intensive interdisciplinary approach 
provided on acute inpatient rehabilitation. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. You have had a functional decline from 
your baseline level of function and would benefit from therapy, but you do not require the intensity of therapy 
provided on acute inpatient rehabilitation. Our physician reviewer found that your condition does not meet 
Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee 
without contrast. 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this 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 this 
service is not medically necessary. Our physician reviewer found that based on the medical records provided, 
there is no clear documentation that the requested MRI of the knee at issue in this case meets Medicare criteria 
as medically reasonable and necessary. There is concern about meniscal pathology. The records provided do 
not document locking, catching or instability of the knee. The reported physical examination of the knee 
reports no joint line tenderness, decreased range of motion, positive McMurray or Apley test, and the records 
are inconsistent with regard to the presence of an effusion. The records are not clear as to how much physical 
therapy treatment the enrollee has had and the specific outcomes of that therapy.   
 
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 right knee without contrast.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit for the evaluation and management of a 
new patient (99325) provided on November 24, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the medically necessary 
services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
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 99325 is domiciliary or rest home visit for the evaluation 
and management of a new patient, which requires these 3 key components: An expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient 
and/or family or caregiver. 
 
We find that CPT code 99385 is not supported in the record. Specifically, the documentation submitted 
indicates that this enrollee previously received professional services from this physician and billing group. 
Based on this information, we decided that Medicare rules for coverage of the domiciliary visit have not been 
met. Therefore, we decided that the Plan does not have to pay for the rest home visit for the evaluation and 
management of a new patient (99325) provided on November 24, 2021.