Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that documents demonstrate the critical 
necessity for the requested equipment. The enrollee has been on continuous oxygen therapy since December 
21, 2021, due to COPD and chronic respiratory failure. Failure to approve the request would be gravely 
detrimental to the enrollees health and well-being and her ongoing diagnoses. Alternative treatment methods 
have been tried and failed. The Plan denied your request. The Plan says the request for a non-invasive 
ventilator (NIV) is not medically necessary because the documentation does not support that this device meets 
but does not exceed the enrollees need. The documentation does not support that the use of a BiPAP device or 
BiPAP device with AVAPS would not meet the enrollees medical needs or have been found to be ineffective 
in the home setting. 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 the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
thoracic restrictive disease. Pulmonary function testing shows no obstructive pattern. Provided records 
document that the home ventilator is being requested for use in intelligent volume assured pressure support 
(iVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with average volume 
assured pressure support (AVAPS) and a back-up rate. The hospital discharge summary of October 21, 2022, 
recommended "PAP therapy with a set backup rate" for the enrollee's restrictive lung disease. In the almost six 
months since this hospital discharge, provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. 
 
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 (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of a SNF admission. The Plan denied your request. The Plan says the SNF services requested do not 
meet the requirements for approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, there is 
no documentation that daily skilled services are required. Provided records do not document a significant 
decline in the enrollees functional status compared to their recent baseline to necessitate daily inpatient skilled 
therapy services. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis 
in a skilled nursing facility (SNF) setting. Records support that services in the home with home health care or 
in a long-term care facility on a part-time basis are 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic images (D0220) and intraoral - periapical each additional radiographic image 
(D023) provided on December 5, 2022, to December 9, 2022. 
 
You asked the Plan to pay for evaluation and imaging. You say that these should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic images (D0220) and 
intraoral - periapical each additional radiographic image (D023) provided on December 5, 2022, to December 
9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 flex walk system (L5981), axial rotation unit (L5984), and vertical shock reducing pylon (L5988) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a K3 flex walk system, axial rotation unit, and vertical shock reducing pylon. Our Medical Director states that there is not sufficient clinical documentation in the case file of functional need for the technologic or design features of the requested foot/ankle system. Our physician reviewer found that the enrollee's 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 a K3 flex walk system (L5981), axial rotation unit (L5984), and vertical shock reducing pylon (L5988) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code S9500. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
You asked the Plan to pre-approve nerve block. You say that you need to lose weight in order to have your 
knee replacement surgery. You say that you are in pain and cannot walk. You also say that you need this 
injection so that you can remain independent. The Plan denied your request. The Plan says the requested 
injection is 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 nerve block. Our reviewer says that the 
requested nerve block is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of blocks of the genicular nerves is under clinical investigational and subject of 
multiple ongoing clinical trials. Therefore, the reviewer found that the requested nerve block is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology second opinion visit to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve oncology visit. You say that you want a second opinion on your diagnosis. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and you can be 
treated within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an oncology second opinion visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a Sprint peripheral nerve stimulation (PNS) system. 
 
You asked the Plan to pre-approve a Sprint PNS system. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are 
experimental/investigational. 
 
The Plan follows Medicare rules. The rules say that payment may be made for the implantation of dorsal 
column or depth brain stimulators or services and supplies related to such implantation only when the 
conditions listed in the Medicare rules section of this letter have been 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 Sprint PNS system. Our reviewer says 
that the requested services are medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has had trials of physical therapy, nerve blocks, transcutaneous electrical nerve stimulation 
(TENS) and a trial of spinal cord stimulation. The enrollee's medication trials have included gabapentin, 
hydrocodone and topical creams. The enrollee's condition is a specific mononeuropathy which is clearly 
identified. 
 
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 Sprint PNS system have been met. Therefore, we decided that the Plan has to 
pre-approve a Sprint PNS system.  
 
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 the initial hospital care services coded 99223 provided on 
July 21, 2021. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
 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 initial hospital care services. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee was admitted to the hospital 
for a planned transurethral resection of the prostate (TURP) procedure for the prostate. The documentation 
indicates the member remained medically stable and tolerated the procedure. The documentation does not 
support all three criteria: a comprehensive history, a comprehensive exam, and medical decision making of 
high complexity. Therefore, code 99223 is not supported. 
 
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 initial hospital care services have not been met. Therefore, we decided that 
the Plan does not have to pay for the initial hospital care services coded 99223 provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation procedure 
(64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for the wrongful 
denial for intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. 
The Plan denied your request. The Plan says the Intracept intraosseous nerve ablation system requested does 
not meet the requirements for approval. 
 
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 requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 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 intraosseous nerve ablation procedure (64628).
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 is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not specify any complex functional impairments or active 
medical comorbidities thus the complexity of the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Additionally, documentation shows that the enrollee was previously bed bound and does not 
show the enrollee would tolerate an intensive rehabilitation program or any clinically significant goals. 
 
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 pay for procedure code 99244 billed for date of service October 11, 
2022. 
 
You asked the Plan to pay for procedure code 99244. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99244 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99244 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99244 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99244 billed for date of service October 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orthovisc injection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has not had 
viscosupplementation in the past six months. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation for the knee is only covered 
under certain medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has osteoarthritis of the knee. The record indicates that the enrollee has had 
previous viscosupplementation therapy that did not produce relief. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Orthovisc injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 14, 2022, billed with 
codes 81403, 81401, 81405, 81406, 81408, 81479, 81304, 81307 and 81192. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. In addition, this panel is not covered as a screening. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 14, 2022, billed with codes 81403, 81401, 81405, 81406, 81408, 81479, 81304, 81307 and 81192.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2377, E2313, E2311) and 
power seat elevation (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics and power seat elevation. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says that the upgraded 
electronics are not medically necessary to control the power options through the joystick. The Plan also says 
that the power seat elevation feature is not primarily medical in nature and is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are medically necessary when it 
is necessary to control the power options through the joystick. The rules also say that the power seat elevation 
feature is not covered as it is not primarily medical in nature. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the enrollee does not have 
any impairments in her upper extremities and is able to manage the standard control switches. 
 
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 upgraded electronics have not been met. The power seat elevation feature 
(E2300) is not covered as it is not primarily medical in nature. Therefore, we decided that the Plan does not 
have to pre-approve the upgraded electronics (E2377, E2313, E2311) and power seat elevation (E2300).