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

 
We decided that the Plan does not have to pre-approve shoulder arthroscopic debridement and decompression. 
 
You asked the Plan to pre-approve the shoulder surgery. You say that this is a medically necessary procedure. 
The Plan denied your request. The Plan says the documentation does not support the need for this surgery. 
 
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 shoulder surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this 64-year-old female was being treated for pain in the right shoulder; impingement 
syndrome of the right shoulder; other injury of muscle, fascia, and tendon of long head of biceps. She presented 
with intermittent mechanical symptoms and sharp, stabbing pain in the right shoulder. She has had previous 
rotator cuff repair years ago.  
 
Detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. She is noted to have trialed 7 sessions of physical therapy between 
6/17/21-8/3/21, and then requested to be discharged. The documentation does not support any significant use of medications and/or the trial and failure of injections for the right shoulder. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested shoulder arthroscopic debridement and decompression, in this 
case, 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 shoulder surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopic debridement and decompression.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81519) provided on June 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has 
been exceeded. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 81519 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services (81519) 
provided on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve home oxygen for three months. We decided that the Plan does not 
have to pre-approve home oxygen beyond three months. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that 
the services are not medically necessary. 
 
We decided that the Plan has to pre-approve home oxygen for three months. 
 
The Plan must follow Medicare rules. Medicare rules say that home oxygen is covered when specific criteria 
are met. 
 
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 medically necessary for three months. Our physician reviewer found that the enrollee was 
hospitalized from April 20, 2022 to April 27, 2022 with acute hypoxic respiratory failure and was found to 
have coronary artery disease and ischemic cardiomyopathy and was stented. He was discharged with oxygen. 
The records show a home oxygen assessment on April 22, 2022 while in the hospital, not within two days of 
discharge, that demonstrated a need for oxygen during exercise but not at rest. There is a high suspicion of 
obstructive sleep apnea. Follow up medical visits have not included oxygenation assessment. It is likely he is 
hypoxemic at night, but it unknown how much of that may be caused by obstructive sleep apnea. Abruptly 
discontinuing oxygen at this point may place him at risk for adverse consequences; therefore, home oxygen is 
medically necessary for three months. This will provide time for repeat oxygenation assessment and overnight 
oximetry or a sleep study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home oxygen therapy for three months have been met. Therefore, we decided 
that the Plan has to pre-approve home oxygen for three months. 
 
We also decided that the Plan does not have to pre-approve home oxygen beyond three months. 
 
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 beyond three months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home oxygen therapy beyond three months have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home oxygen beyond three months. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable pulse generator (IPG) placement. 
 
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 there are not enough studies to show the Implantable Pulse 
Generator is better than other regular treatments. 
 
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. While clinical 
studies led to FDA approval in 2019, cardiac contractility modulation (CCM) remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit. Our physician reviewer found that your 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 implantable pulse generator (IPG) placement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on November 8, 
2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87641, 87150) provided on September 22, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 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 87641 
is a column II code to column I code 87150. We have also confirmed that code 87150 is a column II code to 
column I code 87500. 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 the services (87641, 87150) provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 83631, 83520, 82656, 
82274, and 82705-XU) provided on April 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 83631, 
83520, 82656, 82274, and 82705-XU) provided on April 13, 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 does not meet 
criteria. 
 
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 is medically stable and does not need PM&R physician's supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. The enrollee does not need intensive therapies consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach in an IRF. The enrollee's rehab needs can be 
safely provided in a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile cardiac outpatient telemetry (MCOT). 
 
You asked the Plan to pre-approve mobile cardiac outpatient telemetry. You say that this device is medically 
necessary. The Plan denied your request. The Plan says there is no documentation as to why the MCOT system 
is 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 mobile cardiac outpatient telemetry. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a 94-year-old woman with recent transcatheter aortic 
valve replacement (TAVR). At issue is whether the requested authorization for an mobile cardiac outpatient 
telemetry (MCOT) monitor is medically necessary. There is no supportive evidence that the ordering 
practitioner documented any standard, non-MCOT, ambulatory electrocardiogram (ECG) monitoring. In 
summary, there is insufficient documentation to support the medical necessity for an MCOT monitor in this 
patients 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 mobile cardiac outpatient telemetry have not been met. Therefore, we decided 
that the Plan does not have to pre-approve mobile cardiac outpatient telemetry (MCOT).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve selective catheter placement, arterial system; initial third order or 
more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family (CPT code 
36247). 
 
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 that the enrollee's records do not show that the enrollee has symptomatic 
claudication that is limiting their lifestyle or that has not responded to exercise. The Plan states surgical 
procedures are not recommended in patients with peripheral artery disease solely to prevent progression to 
critical limb ischemia due to the risk of harm. 
 
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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation supports the medical necessity of the treatments in question. The enrollee 
has documented new wounds associated with significant peripheral arterial disease (PAD) as demonstrated by 
abnormal ankle brachial index (ABIs) and evidence of popliteal and tibioperoneal trunk stenosis on duplex. 
Both the wounds and the areas of stenosis represent progression of disease from the enrollee's previous visit. 
These findings may be consistent with limb threatening ischemia and angiography with possible intervention is 
indicated.  
 
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 been met. Therefore, we decided that the Plan has to pre-
approve selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or 
lower extremity artery branch, within a vascular family (CPT code 36247).  
 
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 does not meet 
criteria. 
 
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 is medically improving and does not need PM&R physician's supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. The enrollee does not need intensive therapies consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach in an IRF. The enrollee's rehab needs can be 
safely provided when medically stable in a lower intensity and alternate setting such as in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 
 
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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have a diagnosis of chronic obstructive pulmonary disease (COPD), and has severe obesity. 
There are no pulmonary function tests to assess severity of the COPD. You were recently hospitalized with an 
exacerbation of heart failure with preserved ejection fraction (HFpEF), and arterial blood gas (ABG) showed 
evidence of chronic carbon dioxide (CO2) retention, although there is no ABG done as an outpatient while 
stable to confirm this. You may benefit from bilevel positive airway pressure (bipap) during sleep in the 
average volume-assured pressure support (AVAPS) mode. Medicare does not pay for a home ventilator when 
used as bipap. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
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 does not meet 
criteria. 
 
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 is medically stable and does not need PM&R physician's close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. The enrollee is unlikely to make a significant functional progress with memory 
deficits in a predicted 14 days in an IRF and hence did not require 3 hours a day five days a week of IRF 
therapies with interdisciplinary management. The enrollee's rehab needs could be provided in an alternate and 
low intensity setting such as in a skilled nursing facility. 
 
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 the nutritional therapy (97802, 97803). 
 
You asked the Plan to pre-approve the nutritional therapy. You say that the service should be covered. The Plan 
denied your request. The Plan says there is no documentation that the patient has kidney disease or diabetes. 
 
The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy services is covered for 
beneficiaries who have diabetes or a renal disease. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nutritional therapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve the nutritional therapy (97802, 97803).