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

 
We decided that the Plan does not have to pay for the procedure coded 77065 provided on May 10, 2022. 
 
You asked the Plan to pay for the procedure coded 77065. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
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 77065 
is a column II code to column I code 77066 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the procedure coded 77065 provided on May 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 PT visits. You say that the enrollee needs PT. The Plan denied your 
request. The Plan says additional PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that in this case, the enrollee has previously been treated with 
outpatient therapies and should be independent with a home exercise program. There is no documentation of a 
recent injury or decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 21, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot drop splint (CPT code L4398). 
 
You asked the Plan to pre-approve the foot drop splint. You say that the foot drop splint is necessary. The Plan 
denied your request. The Plan says your primary means of getting around is a wheelchair, you are considered 
non-ambulatory. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the foot drop splint have not been met. Foot drop splints are not 
covered for someone with foot drop who is non-ambulatory (does not normally walk around on your feet). 
Since your primary means of getting around is a wheelchair, you are considered non-ambulatory. Therefore, 
criteria for coverage are not met. Therefore, we decided that the Plan does not have to pre-approve the foot 
drop splint (CPT code L4398).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revita skin substitute. 
 
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 requested Revita is unproven and 
not medically necessary for any indication due to insufficient evidence of efficacy. The services are not 
reasonable or medically necessary for the enrollee 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 Revita skin substitute.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the SI injection (CPT code 27096). 
 
You asked the Plan to pre-approve the SI injection. You say that the service is necessary. The Plan denied your 
request. The Plan says that the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SI injection. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the request meets the criteria and medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SI injection have been met. Therefore, we decided that the Plan has to pre-
approve the SI injection (CPT code 27096).  
 
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 the osteogenesis stimulator (CPT code E0747). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that the osteogenesis stimulator is 
necessary. The Plan denied your request. The Plan says the bone growth stimulator 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 osteogenesis stimulator. Our 
physician reviewer found there is inadequate documentation to meet the requirements listed in the NCD and 
LCD for Medicare coverage of the requested osteogenesis stimulator. Provided records do not document "6 or 
more months have elapsed without healing of the fracture" and "no clinically significant evidence of fracture 
healing" have occurred as required by the NCD and LCD. Imaging from January 27, 2022, shows: "healing 
distal femur shaft fracture." The most recent imaging of the right knee from August 24, 2022, shows: "healed 
posttraumatic deformity of the distal femur with possible persistent fracture lucency along the anterior cortex of 
the metaphysis seen on lateral view." Although a possible fracture lucency persists on imaging, this does not 
appear to be a definite finding as further imaging with magnetic resonance scanning is proposed to evaluate 
your knee pain further. Also, the provided imaging does show some clinically significant evidence of fracture 
healing. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the osteogenesis stimulator (CPT code E0747).
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 services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the requested services are 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 provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF 
admission 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has endured a complex 
hospitalization. You say that they need continued acute care. You also say that the enrollee will be placed on a 
specialized respiratory program with all therapy modalities at the LTACH. The Plan denied your request. The 
Plan says the requested services are 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 the provided documentation indicates that the enrollee is stable and improving. The 
reviewer found that the necessary services can be safely provided at the current facility until more appropriate 
for a lower level of care. The reviewer found that transfer to the LTACH is not medically necessary as it would 
not be clinically advantageous at this time. Therefore, the reviewer found that the requested LTACH care is not 
medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric (J1437). 
 
You asked the Plan to pre-approve Monoferric. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Venofer (iron sucrose). 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Monoferric. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug. The reviewer found that there is no 
documentation provided indicating that the Plans required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric (J1437).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted case management (CPT code T1017). 
 
You asked the Plan to pre-approve the services. You say that you would benefit greatly from being able to 
continue your therapy. The Plan denied your request. The Plan says there is no documented evidence that you 
have the required medical necessity for the requested services. 
 
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 services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you do not require targeted case management services for the treatment 
of your mental health disorder as it is not considered medically necessary or reasonable. 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 
targeted case management (CPT code T1017).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve a laparoscopy procedure and inpatient hospital stay. 
 
You asked the Plan to pre-approve a laparoscopy procedure and inpatient hospital stay. You say that the 
records provided support the need for the requested services. The Plan denied your request. The Plan says that 
the requested procedure and related hospital stay are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that laparoscopic sleeve gastrectomy is covered for 
certain medical indications. 
 
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 laparoscopy procedure and inpatient 
hospital stay. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found that 
the enrollee meets the criteria for the requested bariatric procedure given a BMI that is greater than 35, failed 
weight loss efforts, and at least one obesity related condition. The enrollee has a BMI of 53, asthma, GERD, 
hypertension, and back pain. The enrollee has failed dietary efforts in the past, including medications. The 
requested laparoscopic sleeve gastrectomy is a standard inpatient only procedure. One acute inpatient day is 
considered, at minimum, to be standard and supported by published guidelines and Medicare.  
 
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 laparoscopy procedure and inpatient hospital stay have been met. Therefore, 
we decided that the Plan has to pre-approve a laparoscopy procedure and inpatient hospital stay.  
 
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 power wheelchair and accessories (K0837, E2361, 
E1028, E1007, E2311, E1012). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary, and you cannot use a walker for your ambulation needs. The Plan 
denied your request. The Plan says you depend on walker access to decrease stress on the residual left leg due 
to pain. You have a manual wheelchair that you can propel throughout the home and up and down a ramp to go 
outdoors. Medicare rules require the requested PWC to be functional within the home to perform ADL. Based 
on a periscope report, your home is not accessible and would not allow access to the bathroom. You desire use 
primarily in the community because a power scooter is not always available. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair and accessories (K0837, E2361, E1028, E1007, E2311, E1012).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
18, 2022, to April 30, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the NOA 
submitted has an admission date that does not match the first date services were rendered. This claim is not 
payable as billed. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from April 18, 2022, to April 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the requested manual wheelchair is 
medically necessary and beneficial to the enrollee. The Plan denied your request. The Plan says the enrollee's 
doctor did not send records that show what type of wheelchair is needed. The Plan does not see that the 
enrollee takes a very long time to do daily activities, that the enrollee cannot safely use a cane or walker, the 
enrollee is able to propel a wheelchair or have someone who can. The Plan also says that criteria is not met for 
the requested wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a wheelchair will not be covered if the patient does 
not have mobility deficit that impairs their participation in MRADLs, the patients condition can be 
ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the 
requested manual wheelchair.  
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, or your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a manual wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110) provided on December 31, 2020. You asked the Plan to pay for therapy services. You say that these services were medically necessary and were 
billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that these services are not supported in the medical record. Specifically, the documentation shows that 
this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapy services have not been met. Therefore, we 
decided that the Plan does not have to pay for therapy services (97110) provided on December 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychosocial rehabilitation services (H2018). 
 
You asked the Plan to pre-approve the services. You say that you would benefit greatly from being able to 
continue your therapy. The Plan denied your request. The Plan says the targeted psychiatric condition, 
symptoms, and behaviors documented are not appropriate for psychosocial rehabilitation level of care. 
 
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 services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you do not meet the criteria for psychosocial rehabilitation services and 
could be treated at a lesser restrictive environment as the procedure is not considered reasonable or medically 
necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve psychosocial rehabilitation services (H2018).