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

 
We decided that the Plan does not have to pre-approve an Orthovisc injection (J7324). 
 
You asked the Plan to pre-approve an Orthovisc injection. You say that the requested service is necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
the conditions 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 an Orthovisc injection. Our reviewer 
says that the requested Orthovisc injection is not medically necessary. Our physician reviewer found the 
provided documentation does not support that the enrollee has had any imaging done. The reviewer found that 
there is no documentation to support that the enrollee has completed any physical therapy. The reviewer also 
found that there is no documentation to support any weight loss therapies have been completed. Therefore, the 
reviewer found that the requested Orthovisc injection is not medically reasonable or necessary 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 an Orthovisc injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Orthovisc injection (J7324).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a Transcutaneous electrical nerve stimulation (TENS) device (E0730). 
 
You asked the Plan to pay for the TENS device. You say that you did not benefit from the device and you 
offered to return it to the supplier. The plan made some payments but did not make other payments for the 
device. The Plan denied your request. The Plan says that the enrollee is responsible for 13 consecutive 
payments for this device. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan's denial letter does not clearly articulate the plan's denial of coverage. 
The plan states that the enrollee is responsible for making 13 consecutive payments, however the records show 
that the plan did make multiple payments for this item and made other payments at different amounts. 
Therefore, we decided that the Plan has to pay for a Transcutaneous electrical nerve stimulation (TENS) device 
(E0730).  
 
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 pay for principal care management services provided on June 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the principal care management services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says a referral/authorization was not obtained 
prior to services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for principal care management services provided on 
June 21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483). 
 
You asked the Plan to pre-approve a repeat TFESI. You say that this injection is medically necessary due to 
radiculopathy. The Plan denied your request. The Plan says the requested repeat injection is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least 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 a repeat TFESI. Our reviewer says that 
a repeat TFESI is not medically necessary. Our physician reviewer found the provided documentation does not 
support that the enrollee had 50% pain relief for 3 months. Therefore, the reviewer found that the requested 
TFESI 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 a repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Nodify CDT test (code 81599) provided on April 13, 2022. 
 
You asked the Plan to pay for the Nodify CDT test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that this test is considered experimental. 
 
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 pay for the Nodify CDT test. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this testing is not considered experimental.  The Journal of Thoracic Oncology published a 
research letter stating that the 2-year follow-up extended analysis of the PANOPTIC trial confirms the accuracy 
of an integrated classifier in patients with indeterminate pulmonary nodules with pCA = 50%, whether solitary 
or multiple. These results substantiate the case for a clinical utility study to determine how the integrated 
classifier impacts physician decision-making and patient outcomes. 
 
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 Nodify CDT test have been met. Therefore, we decided that the Plan has to 
pay for the Nodify CDT test (code 81599) provided on April 13, 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 custom foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve custom 
foot orthotics.
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 requested services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the 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 does not require services at the 
LTACH that are not already available at the current facility. The reviewer also found that transfer to the 
LTACH is not medically necessary as it would not be clinically advantageous 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint procedure 
(64635, 64636). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the request is for CPT 64635 left 
LK5/S1. No prior fusion in the level being requested. The Plan denied your request. The Plan says The clinical 
value and effectiveness of radiofrequency ablation to the SI joint in the setting of sacroiliac joint pain 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental/ investigational due to the wide variation in 
efficacy reported in the literature.  Therefore, the request is deemed 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation to the SI joint procedure (64635, 64636).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 6, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for these services. You say that you are appealing with supporting documentation 
and are requesting this claim be promptly processed and reconsidered for payment. The Plan denied your 
request. The Plan says the enrollee must receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the services provided on April 6, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on July 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that this should be covered. The 
Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on 
July 19, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has been diagnosed with an acute 
cerebral vascular accident and diagnosed with encephalopathy. The Plan denied your request. The Plan says 
based on Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 functioning well post a complicated hospital stay. She is 
deconditioned and functioning at a level of rehabilitation need routinely managed without IRF stay. There are 
no complex nursing or rehabilitation needs. The enrollee's medical issues are not an indication for an IRF 
admission and are not a barrier to access to standard post-acute rehabilitation services provided at levels of care 
other that 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral device/appliance used to reduce upper airway 
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (E0486). 
 
You asked the Plan to pre-approve an oral device/appliance. You say that the enrollee is intolerant of CPAP 
modalities and is opting for treatment with an FDA approved oral appliance to manage upper airway collapse 
during sleep. The Plan denied your request. The Plan says that the records show that the enrollee does not meet 
the requirements for approval. 
 
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 an oral device/appliance. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has symptoms of OSA and was evaluated by a physician via video. The 
record includes an appropriate history and detailed upper airway examination. This is the equivalent of an in-
person visit. The home sleep study was done over 2 days. The severity was moderate on one day (AHI 16) and 
severe on the second day (AHI 41). If the two nights are averaged, the AHI is less than 30, which is moderate. 
The enrollee does not want CPAP, and desires treatment with the oral appliance. The records include a post-test 
video visit and a dental visit. Thus, Medicare criteria are 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 an oral device/appliance have been met. Therefore, we decided that the Plan has 
to pre-approve an oral device/appliance used to reduce upper airway collapsibility, adjustable or non-
adjustable, custom fabricated, includes fitting and adjustment (E0486).  
 
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 you almost died in your hospital bed, and you need 
physical therapy to gain strength. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF), 
outpatient setting, or home health care. 
 
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 you were admitted for syncope. Your medical problems are stable, and there are no 
complex nursing or rehabilitation needs. You do 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. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
provided to the enrollee on March 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee was ultimately discharged home in stable condition with no risk or threat to life. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented to the 
emergency department with high blood pressure after taking home blood pressure medications. She reported no 
symptoms. Upon evaluation, blood pressure readings ranged from 158/70 to 186/84. The workup was 
unremarkable. Emergency department services (procedure code 99285) was not provided to the enrollee on 
March 10, 2022, as there was no evidence of a high severity, high complexity clinical scenario with immediate 
significant threat to life or physiological function based on the provided documentation. The patient was given 
antihypertensives but was not in a hypertensive urgency or emergency setting.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (procedure code 99285) provided to the enrollee on March 10, 
2022.