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

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 72170. You say that this service was not billed with any other 
services. The Plan denied your request. The Plan says payment for code 72170 is bundled into payment for 
code 72190. 
 
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 72170 
is a column II code to column I code 72190, which was billed on a separate claim for the same date and 
enrollee by the same provider. 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 procedure code 72170 billed for date of service February 25, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from January 26, 2022, to February 
24, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that payment 
is not allowed for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and the rules. The submitted claim shows that the value codes and amounts were billed as 
required. Based on this information, we decided that Medicare rules for coverage of the services provided have 
been met. Therefore, we decided that the Plan has to pay for the home health services provided from January 
26, 2022, to February 24, 2022.  
 
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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode with Auto-
EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. The record indicates that you have chronic 
respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation 
does not contain sufficient detailed information in the medical record to justify the treatment selected. You 
could be treated with a BiPAP machine with AVAPS capability. Our physician reviewer found that your condition does not meet Medicare criteria for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home 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 you do not meet criteria for IRF admission. 
 
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 you do 
not meet criteria for IRF admission. Our physician reviewer found the complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You were admitted for subdural hematoma after a fall and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71271 billed for date of service October 14, 
2021. 
 
You asked the Plan to pay for procedure code 71271. You say that this claim was denied as a duplicate in error. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 19, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 71271 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 71271 billed for date of service 
October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on October 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is 
not payable for these services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
provided on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented, calibrated gradient pneumatic 
compression device represented by code E0652 and a segmental pneumatic appliance for use with a pneumatic 
compressor represented by code E0667. 
 
You asked the Plan to pre-approve codes E0652 and E0667. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says there is no evidence of any chest, trunk, or abdominal 
swelling. 
 
The Plan follows Medicare rules. Medicare rules say that a segmented, calibrated gradient pneumatic 
compression device is only covered when the individual has unique characteristics which prevent them from 
receiving adequate satisfactory pneumatic compression treatment using a nonsegmented device along with a 
segmented appliance or compression device without manual control of the pressure in each chamber. 
 
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 codes E0652 and E0667. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the only unique 
characteristics identified in the clinical literature that requires the use of an E0652 device is lymphedema 
extending onto the chest, trunk and/or abdomen which has remained unresponsive to all other therapies. In this 
case, the record indicates that the enrollee has lymphedema. The record does not indicate that the lymphedema 
extends onto the chest, trunk and/or abdomen.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E0652 and E0667 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a segmented, calibrated gradient pneumatic compression device represented by 
code E0652 and a segmental pneumatic appliance for use with a pneumatic compressor represented by code 
E0667.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot tolerate three hours of therapy in 
the acute setting and would benefit in a SNF environment. The Plan denied your request. The Plan says the 
enrollee is currently at an inpatient rehabilitation facility, the records show that the enrollee continues to require 
intensive therapy and will continue to benefit from rehabilitation services. The Plan also says that transfer to 
SNF is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are identifiable skilled therapy service needs. However, the beneficiary does not 
require skilled nursing or therapy services on a daily basis. The beneficiary does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound guidance for trigger point injections (76942) 
provided January 20, 2022. 
 
You asked the Plan to pay for the ultrasound guidance. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 pay for the ultrasound guidance. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found ultrasound has not been found to improve the efficacy of trigger point injections. 
 
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 ultrasound guidance have not been met. Therefore, we decided that the Plan 
does not have to pay for ultrasound guidance for trigger point injections (76942) provided January 20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional chiropractic visits. 
 
You asked the Plan to pre-approve additional chiropractic visits. You say that additional chiropractic visits are 
medically necessary as it is helping you post back surgery. The Plan denied your request. The Plan says that 
additional chiropractic visits are not medically necessary as additional chiropractic visits are considered to be 
maintenance therapy. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in 
function.   
 
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 chiropractic visits. Our reviewer says 
that additional chiropractic visits are medically reasonable and necessary. Our physician reviewer found that 
the last available follow up visit note documents you were in the repair phase of healing and continued 
improvement was documented compared to previous visits, with reduced pain levels. Our physician reviewer 
also found that the clinical documentation does not support that you have a chronic condition and had reached 
the point of maintenance 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 chiropractic visits have been met. Therefore, we decided that the Plan has to 
pre-approve additional chiropractic visits.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227) provided on 
October 19, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these are payable by Medicare and that they 
were denied as experimental in error. Medical records were attached for review. The Plan denied your request. 
The Plan says the testing was ordered to direct further treatment for the generalized anxiety disorder, not for the 
indications under CMS rules and guidance. 
 
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 pay for laboratory services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is inadequate documentation that the gene analysis testing provided on 10/19/2021 at 
issue in this case meets LCD (Local Coverage Determination) criteria for coverage. Provided records do not 
include any clinical visit notes documenting the necessity of the gene analysis testing provided on 10/19/2021 
or how the test would directly impact treatment or management of the enrollee as required by the LCD; the 
only records provided were the test requisition form and the test result report. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (81225, 81226, 81227) provided on October 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve two additional physical therapy sessions. You say that the enrollee needs 
additional PT before being discharged. The Plan denied your request. The Plan says the medical criteria has not 
been met.   
 
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 two additional physical therapy 
sessions. 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 the additional requested therapy 
generally is not accepted as specific and effective therapy for the enrollees condition beyond what was 
approved by the Plan. The enrollee has had prior therapy and the documentation does not reveal that the 
enrollee requires the unique skills of a professional therapist to safely and effectively provide treatment. The 
enrollee has been educated on safety and a home exercise program. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the enrollees current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two additional physical therapy sessions have not been met. Therefore, we 
decided that the Plan does not have to pre-approve two additional physical therapy (PT) sessions.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a total knee arthroplasty (27447 and 27446). 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that the requested total knee arthroplasty 
is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
the requested total knee arthroplasty (27447 and 27446). 
 
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 a total knee arthroplasty. Our reviewer 
says that the enrollee meets criteria for the requested total knee arthroplasty (27447 and 27446). Our physician 
reviewer found the enrollee was being treated for unilateral primary osteoarthritis of the right knee. He 
presented with pain that is predominantly medial (but is not sure if it is diffuse or all over.) Height is 5 feet 5 
inches, weight is 157 pounds, and body mass index of 26.13kg/m2. The exam reveals he walks with a very 
significant varus thrust on the right knee. Stance is bilateral bowed legs, worse on the right. He seems to have 
bilateral flexion contractures of 10 to 15 degrees. There is 50% joint space narrowing. 
 
In this case, there is well documented, as evidenced on x-rays of the knees on November 6, 2019, September 
21, 2021, and May 10, 2022, of severe arthritis that is worse on the right knee. He has tried and failed physical 
therapy, a home exercise program, and injections (cortisone and viscosupplementation). Provided 
documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial 
and failure of conservative treatment modalities have been documented. Therefore, the enrollee does meet LCD 
criteria for the requested total knee arthroplasty. 
 
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 total knee arthroplasty have been met. Therefore, we decided that the Plan has 
to pre-approve a total knee arthroplasty (27447 and 27446).  
 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 percutaneous injection of VIA Disc (0627T). 
 
You asked the Plan to pre-approve percutaneous injection of VIA Disc. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules 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 percutaneous injection of VIA Disc. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that there is little evidence in the medical literature to suggest that the 
requested services an appropriate procedure for the enrollees back pain. The requested services are not an 
accepted standard of medical practice for the diagnosis or treatment of back pain and are considered 
experimental and investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous injection of VIA Disc have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous injection of VIA Disc (0627T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services you received on March 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services you received 
on March 22, 2022.