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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. 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. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD). There is no diagnosis of bronchiectasis, cystic fibrosis, or neuromuscular disease. The HFCWOD is not covered for the treatment of COPD. The services are therefore not reasonable or 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 1, 2022, billed with 
codes 87632, 87633, 0115U, 0202U, 0223U, 0225U, 87633, 87150, 87486, 87541, 87581, 87641, 87651, and 
87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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. Medicare rules also say that for lab services, the POS code must reflect 
the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Codes 87632, 87633, 0115U, 0202U, 0223U, and 0225U were an 
NGS panel that was not billed with a single panel code as required. Code 87633 is specifically not covered as it 
is infectious agent detection by nucleic acid, 12-25 targets. Any panels with greater than five respiratory 
pathogens are not covered. Codes 87150, 87486, 87541, 87581, 87641, 87651, and 87801 were billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
 
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 June 1, 
2022, billed with codes 87632, 87633, 0115U, 0202U, 0223U, 0225U, 87633, 87150, 87486, 87541, 87581, 
87641, 87651, and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation. 
 
You asked the Plan to pre-approve SI joint RFA. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 pre-approve SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found RFA of the lateral sacral branches is considered experimental due to the wide variation in 
efficacy reported in the literature. Therefore, the procedure was 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 SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation.
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 enrollee requires acute rehabilitation to regain 
strength and mobility to return home. The Plan denied your request. The Plan says the IRF 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee 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. Our physician reviewer also found that there is not a reasonable expectation that this 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.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for codes 37228 and 37224. We decided that the Plan does not have to pay 
for codes 75710 and 75625.  
 
You asked the Plan to pay for the services (37228, 37224, 75710, 75625) provided on July 1, 2022. The Plan 
says that the billed services are not supported. 
 
 
 
 We decided that the Plan has to pay for codes 37228 and 37224.  
 
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 37228 is "Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial 
vessel; with transluminal angioplasty". The CPT Code Manual, definition of code 37224 is "Revascularization, 
endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty". 
 
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 codes 37228 and 37224. Our reviewer says that the use of 
codes 37228 and 37224 is supported by the records provided. Our reviewer found that the operative report 
describes revascularization of the Tibialperoneal Trunk (TPT), which would be reported with CPT 37228. 
Additionally, the operative report describes revascularization of popliteal artery, which would be reported with 
CPT 37224. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 37228 and 37224 have been met. Therefore, we decided that the Plan has 
to pay for codes 37228 and 37224 provided on July 1, 2022. 
 
We also decided that the Plan does not have to pay for codes 75710 and 75625. 
 
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 codes 
75710 and 75625 are column II codes to column I code 93458. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services 75710 and 
75625 provided on July 1, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 30, 2022, to July 2, 
2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the physician's judgement to admit 
and treat the enrollee as an inpatient was necessary and appropriate. The Plan denied your request. The Plan 
says that these services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found although the enrollee's white blood cell count was normal, the finding of evidence 
suggestive of possible peritonitis from the paracentesis warranted closer observation and hospitalization until 
symptoms resolved and/or culture was negative to rule it out which would require at least 2 days. Our reviewer 
found that therefore, it was expected that the enrollee would require hospital services that would likely cross 2 
midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Though the enrollees enrollment was 
terminated with the Plan on June 30, 2022, they were also admitted on June 30, 2022, while they were still 
under contract, therefore this claim is coverable. Based on this information, we decided that Medicare rules for 
coverage of the acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from June 30, 2022, to July 2, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device. 
 
You asked the Plan to pre-approve a Minuteman G3R Interspinous device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have 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 pre-approve a Minuteman G3R Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Minuteman G3R interspinous device at L3-4 or L4-5, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Minuteman G3R Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver and 
related supplies. 
 
You asked the Plan to pre-approve the CGM monitor and supplies. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says the records show that the enrollee does not 
require at least three injections of insulin per day, that the enrollee is not on an insulin pump, and that the 
enrollee does not make frequent changes in their insulin regimen based on the results of a glucose monitor. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM monitor and supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical 
records provided do not demonstrate that the enrollee is taking 3 shots of insulin daily. The records also do not 
demonstrate that the enrollee is adjusting Novolog dosing based on blood glucose levels. 
 
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 CGM monitor and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs are only covered for certain 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 a lumbar epidural steroid injection. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has a history of chronic low back pain due to lumbar 
degenerative disc disease. The enrollee tried and failed conservative treatment. The enrollee's first epidural 
steroid injection (ESI) was on August 1, 2022, and the next ESI was six weeks later on September 12, 2022. 
The enrollee states the pain relief improved by approximately 75%, but pain relief lasted only for two weeks. This means the most recent epidural steroid injection provided 75% pain relief for a period of two weeks. The 
enrollee does not meet criteria for the requested 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 a lumbar epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you need this. The Plan denied your request. 
The Plan says this provider is out-of-network with the Plan, you can be treated within the Plan network, and it 
is unclear whether you will benefit from physical therapy. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 5, 2022 to January 
27, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case the NOA claim was not filed with a valid type of bill or a valid one-time admission date of January 
1, 2022. Therefore, we decided that the Plan does not have to pay for home health services provided on January 
5, 2022 to January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner with seat lift mechanism. 
 
You asked the Plan to pre-approve the requested chair with seat lift mechanism. You say that this seat lift 
would greatly improve your mobility and your level of function. The Plan denied your request. The Plan says 
you do not meet the criteria for the requested seat lift. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is only covered if all of the 
conditions listed in the Medicare rules section are met. 
 
We looked at the file and Medicare rules. There is no evidence that you have one of the covered conditions for 
this item. Also, there is no evidence that this seat lift is being prescribed as part of your treating practitioner's 
course of treatment, as there is no evidence of a physician order. Based on this information, we find that the 
Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a recliner with seat lift mechanism.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve injections at the first and second levels. We decided that the Plan 
does not have to pre-approve injection at a third level.  
 
You asked the Plan to pre-approve facet joint injections. You say that the injections are medically necessary for 
the enrollee. 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 injections for one to two levels, either 
unilateral or bilateral, are allowed per session per spine region. 
 
We decided that the Plan has to pre-approve injections at the first and second levels.  
 
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 injection at a third level. Our 
reviewer says that injections at a first and second level are medically necessary. Our physician reviewer found 
the enrollee received 100% pain relief initially. Therefore, the reviewer found that injections at the first and 
second level and 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 injections at the first and second level have been met.  Therefore, we decided 
that the Plan has to pre-approve injections at the first and second levels.  
 
We also decided that the Plan does not have to pre-approve injection at a third level. 
 
The reviewer also found that the guidelines only support coverage for these injections at the first and second 
level. Therefore, the reviewer also found that an injection at a third level 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 the injection at a third level have not been met. Specifically, the benefit limit of 
one or two levels has been exceeded. Therefore, we decided that the Plan does not have to pre-approve 
injection at a third level. 
 
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.