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

 
We decided that the Plan does not have to pre-approve a cochlear implant.  
You asked the Plan to pre-approve a cochlear implant. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that the cochlear implantation is covered for the 
indications established in the applicable NCD. 
 
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 cochlear implant. Our reviewer says 
that the requested cochlear implant is not medically reasonable and necessary. Our physician reviewer found 
that the record indicates that the enrollee has chronic serous sinusitis and impacted cerumen. Hearing testing 
performed in April 2022 demonstrates a 63% accuracy rate in the right ear in the best-aided listening 
condition. The record does not provide subsequent testing results after treatment of the impacted cerumen and 
resolution of the chronic sinusitis. The elements of the coverage criteria are not satisfied. 
 
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 cochlear implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cochlear implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the power operated vehicle requested is not the most appropriate mobility device for you 
at this time. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD 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 PMD.  
 
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 DME. Our physician reviewer 
found you are able to perform your activities of daily living (ADLs) in the home. A power scooter is available 
when a person is unable to perform mobility associated ADLs. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve power operated vehicle, group 1 standard, patient weight capacity up to and including 300 
pounds (CPT code K0800).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility (SNF) care is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage of the requested services. 
 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 that daily skilled services are not required. Although records document that the 
enrollee is very limited functionally, the provided records do not document a significant decline in the 
enrollee's functional status compared to his recent baseline to necessitate daily inpatient skilled therapy 
services. Additionally, as a practical matter, the enrollee does not require the services on an inpatient basis, 
only in a skilled nursing facility setting. The records do not support that services in the assisted living facility 
with home health care (or hospice) or in a long-term care facility on a part time basis are not appropriate in this 
case. 
 
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 inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical branch blocks (MBBs) (64493, 64494, 64495). 
 
You asked the Plan to pre-approve MBBs. You say that the enrollee has constant achy pain. You say that the 
pain radiates. You say that the pain is alleviated by Tramadol. You also say that the lumbar epidural steroid 
injection provided 20% reduction in pain symptoms for about a week. The Plan denied your request. The Plan 
says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically 
reasonable and necessary in the absence of untreated radiculopathy or neurogenic claudication. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has radicular pain in bilateral hips. Therefore, the reviewer found that the requested 
MBBs 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 MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve medical branch blocks (MBBs) (64493, 64494, 64495).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial of 
admission to a LTACH. The Plan denied your request. The Plan says that the coverage criteria has not been 
met. 
 
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 that the enrollee appears to be improving but still somewhat unstable and should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that you believe it is in the enrollee's 
best interest to undergo the small bowel video capsule study. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a wireless capsule endoscopy. Our 
reviewer says that the requested wireless capsule endoscopy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the available records do not support the immediate 
necessity of capsule examination of a normal small bowel in the absence of anemia or active bleeding. 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support the need 
for the Intracept procedure. The Plan denied your request. The Plan says the clinical value and effectiveness of 
the Intracept procedure in the setting of chronic low back pain due to degenerative disc disease, vertobrogenic 
pain, and Modic type changes have 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 the Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TENS device (E0730) provided on May 2, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 TENS device have not been met. The Delivery Ticket 
submitted did include the carrier's tracking number, although tracking is unable to be verified with USPS as of 
June 2, 2022, tracking only shows label created but not in system. Proof of Delivery did not include an order 
number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized 
to indicate the specific supplies; therefore, the billed supply code cannot be verified. Unable to verify referring 
provider or any type of established relationship. Therefore, we decided that the Plan does not have to pay for 
the TENS device (E0730) provided on May 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging service (76376) provided on November 24, 
2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76376 
is a column II code to column I code 71275 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 imaging service (76376) provided on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio bracelet. 
 
You asked the Plan to pre-approve the Cala Trio bracelet. You say that this device is medically necessary for 
your condition. The Plan denied your request. The Plan says the requested device is considered 
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 the Cala Trio bracelet. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that although there is some support in the literature for the use of the requested 
device for treatment of essential tremor, the records do not document trial and failure of all conservative 
measures to treat the essential tremor prior to using the Cala Trio device. You are on nicotine therapy which is 
an agent associated with tremor. In addition, failure of control of the tremor with reduction in caffeine intake is 
not documented in the medical record. As trial and failure all first line measures to reduce the essential tremor 
are not documented in the medical record, approval of the Cala Trio device cannot be endorsed 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 the Cala Trio bracelet have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Cala Trio bracelet.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone. 
 
You asked the Plan to pre-approve Dexamethasone. You say that the clinical documentation provided supports 
the need for the requested drug. The Plan denied your request. The Plan says Dexamethasone is a self-
administered drug that is not being used as a full therapeutic replacement for IV anti-emetic drugs that would 
have been administered at the time of the cancer chemotherapy treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone.  
 Benefits for Dexamethasone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of continuous positive airway pressure 
(CPAP) equipment. 
 
You asked the Plan to pre-approve continuation of CPAP equipment. 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 continued coverage of a PAP device (E0470 or 
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document 
that the beneficiary is benefiting from PAP 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 continuation of CPAP equipment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the CPAP equipment at issue in this case meets all of 
Medicare's LCD criteria for medically reasonable and necessary for you. Provided records do not document 
adherence to the CPAP therapy for =4 hours per night on 70% of nights during a consecutive thirty (30) day 
period as required by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of CPAP equipment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continuation of continuous positive airway pressure (CPAP) equipment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks (64454 x 2). 
 
You asked the Plan to pre-approve the injections. You say that these services are 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. 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 injections. Our reviewer says that 
the requested injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of genicular nerve blocks and radiofrequency ablation (RFA) in the therapy of 
osteoarthritis of the knee is still being investigated.  It is currently considered experimental and investigational. 
Therefore, the reviewer found that the requested injections are 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve blocks (64454 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on June 11, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that the claim should be paid. The Plan denied your 
request. The Plan says payment for this claim/service may have been provided in a previous payment. 
 
The Plan must follow Medicare rules. The rules say that The Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care have not been met. The global surgical package for code 49083 is the same day 
as the surgery. Code 99223 was billed on the same day as surgery code abdominal paracentesis (49083). As per 
the 2022 Physician Fee Schedule, abdominal paracentesis is a global surgery. Therefore, the evaluation and 
management service is included in the payment for the surgical procedure. Therefore, we decided that the Plan 
does not have to pay for initial hospital care (99223) provided on June 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit charge for services provided on March 28, 
2022, billed with code 99214-25. 
 
You asked the Plan to pay for the office visit charge. You say that this was a separately identifiable E&M 
service which was resubmitted with the required modifier 25. The Plan denied your request. The Plan says this 
claim was submitted as a replacement to the prior claim; however, only the single E&M code was reported with 
modifier 25. Modifier 25 is not appropriate for use when the E&M code is the only billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier 25 may be appended to an Evaluation & 
Management (E&M) code when reported with another procedure or other service, on the same day of service.  
 
We looked at the file and Medicare rules. Though payment was made for other codes on a previous claim, this 
was submitted as a replacement claim. Since the E&M code was billed with modifier 25 with no other services 
on the claim, it cannot be paid. Based on this information, we decided that Medicare rules for coverage of the 
office visit charge have not been met. Therefore, we decided that the Plan does not have to pay for the office 
visit charge for services provided on March 28, 2022, billed with code 99214-25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (CPT code 95870) provided on 
May 25, 2022. 
 
You asked the Plan to pay for procedure code 95870-26. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
95870-26 is a column II code to column I code 95861. 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 needle electromyography (CPT code 95870) 
provided on May 25, 2022.
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 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. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for surgical management of an intra-abdominal abscess and mass. He is now medically stable with no 
complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. 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. 
 
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.