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

 
We decided that the Plan does not have to pre-approve a hip replacement procedure to be performed by a 
computer assisted MAKO robotic device (CPT code(s): S2900, 20985). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a standard of care to utilize the MAKO robotic system in conjunction with the hip 
replacement procedure has not been established. The Plan states the MAKO device for hip surgeries is still 
considered experimental and investigational. The Plan states there is limited evidence supporting superiority 
(as well as justification of the extra cost) of the MAKO robotic system over traditional surgical procedures. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. The clinical benefits, including ultimate outcomes of functional improvement and pain reduction (with computer navigation over standard 
surgery) is not evident in large-scale, long-term peer-reviewed literature. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested hip replacement procedure to be performed by computer-assisted MAKO robotic 
device, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hip replacement procedure to be performed by a computer assisted MAKO robotic 
device (CPT code(s): S2900, 20985).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of spinal fluid with lower back spinal tap for 
diagnostic test using imaging guidance. 
 
You asked the Plan to pre-approve removal of spinal fluid with lower back spinal tap for diagnostic test using 
imaging guidance. You say that removal of spinal fluid with lower back spinal tap for diagnostic test using 
imaging guidance is medically necessary. The Plan denied your request. The Plan says removal of spinal fluid 
with lower back spinal tap for diagnostic test using imaging guidance 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 removal of spinal fluid with lower back 
spinal tap for diagnostic test using imaging guidance. Our reviewer says that the requested removal of spinal 
fluid with lower back spinal tap for diagnostic test using imaging guidance is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that lumbar puncture for Alzheimer's 
disease markers has not been shown to have sufficient predictive value to have clinical utility that impacts the 
management and outcomes of patients with cognitive dysfunction. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of removal of spinal fluid with lower back spinal tap for diagnostic test using 
imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve 
removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve flex-walk systems (L5981) for bilateral prostheses. 
 
You asked the Plan to pre-approve flex-walk systems. You say that the requested items are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the request 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 flex-walk systems. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the flex-walk system exceeds the enrollee's medical needs. The treating provider's 
documentation does not support that the enrollee is a K3 ambulator, given multiple comorbidities and 
functional level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flex-walk systems have not been met. Therefore, we decided that the Plan does 
not have to pre-approve flex-walk systems (L5981) for bilateral prostheses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee has frequent episodes of low 
blood glucose. She has numerous sores on her fingers from the sticks to check glucose which causes her pain. 
The Plan denied your request. The Plan says the enrollee does not meet coverage criteria of the requested 
CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a re-evaluation (D0170), a treatment simulation 
(D0393), diagnostic casts (D0470), surgical placement of implant body (D6010), bone grafts (D6104), 
collection and application of autologous blood concentrate product (D7921), therapeutic drugs (D9612), and 
medicaments (D9630) for tooth #6, #8, #9, #10, #22, and #27. 

You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the enrollee to 
receive these dental services. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the re-evaluation, treatment simulation, diagnostic casts, surgical placement of 
implant body, bone grafts, collection and application of autologous blood concentrate product, therapeutic 
drugs, and medicaments are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pre-approve a re-
evaluation (D0170), a treatment simulation (D0393), diagnostic casts (D0470), surgical placement of implant 
body (D6010), bone grafts (D6104), collection and application of autologous blood concentrate product 
(D7921), therapeutic drugs (D9612), and medicaments (D9630) for tooth #6, #8, #9, #10, #22, and #27.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 17, 2022, to 
February 1, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that the attending 
physician confirmed the diagnosis in the progress notes. The Plan denied your request. The Plan says the 
documentation was inconsistent with the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J15.6, defined as pneumonia due to 
other Gram-negative bacteria. 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 inpatient 
services at the DRG originally billed. Our physician reviewer found that the enrollee was treated in the hospital 
for a pneumonia with intravenous antibiotics. However, the documentation did not include evidence of a gram-
negative bacteria causing this pneumonia. There was no gram stain, culture, or antigen test result showing 
objective evidence of such. Therefore, the records do not support the diagnosis of J15.6 for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 17, 2022, to February 1, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81479) provided on April 5, 2022, to June 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered when provided OON without prior authorization. 
 
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 the lab services (81479) provided on April 5, 
2022, to June 7, 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is able to tolerate 3 hours a day of 
therapies. The Plan denied your request. The Plan says the enrollee does not need 3 hours of therapy daily to 
meet therapy goals. 
 
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 physician reviewer found 
that the enrollee is status post cervical laminectomy and fusion. She has pain but is neurologically intact per 
neurosurgery. She is at a minimal to moderate assist level for activities of daily living.  She is at a minimal assist level for transferring and walking. The enrollee does not have a spinal cord injury. 
There is no indication for intensive rehabilitation or frequent physiatry oversight. Therefore, an admission to an 
IRF 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex interlaminar stabilization device (CPT) 
code(s): 22867, C1821). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says Coflex is considered investigational as a treatment option for the enrollee's back pain. 
The Plan states this means the treatment is still being developed or it has not been shown to improve health 
outcomes for the enrollee's condition. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Coflex device 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex 
interlaminar stabilization device (CPT) code(s): 22867, C1821).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of acute shoulder dislocation services 
coded 23660 and the incision and drainage of hematoma services coded 10140 provided on June 27, 2022. 
 
You asked the Plan to pay for the open treatment of acute shoulder dislocation services and the incision and 
drainage of hematoma 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. We find that CPT codes 23660 and 10140 are not supported in the medical record. Specifically, code 23660, an 
open treatment of an acute shoulder dislocation is documented in the operative note submitted for review; 
however, this procedure is considered inclusive to CPT code 23473; therefore, this code cannot be verified. 
Code 10140, an incision and drainage of a hematoma, seroma or fluid collection is documented in the operative 
note submitted for review; however, this procedure is considered inclusive to CPT code 23473; therefore, this 
code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the open 
treatment of acute shoulder dislocation services and the incision and drainage of hematoma services have not 
been met. Therefore, we decided that the Plan does not have to pay for the open treatment of acute shoulder 
dislocation services coded 23660 and the incision and drainage of hematoma services coded 10140 provided on 
June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing provided on June 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for COVID-19 testing. You say that you cannot pay the billed amount. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
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 COVID-19 testing provided on June 5, 2022, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable loop recorder (ILR) coded as 33285 and 
C1764. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that please see attached clinical 
information to support this request. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare or the Plan's criteria for an ILR. 
 
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 an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the enrollee has a history of short supraventricular tachycardia (SVT) 
salvos and suspected to be at risk for atrial fibrillation, there is no documentation provided to suggest a history 
of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in this enrollees clinical 
management. 
 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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantable loop recorder (ILR) coded as 33285 and C1764.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning cushion/pillow (E0190), a power 
articulating foot platform (K0108), a custom headrest cover (K0108) and an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee meets criteria for the 
wheelchair accessories. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria for the requested accessories. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  

We looked at the file and Medicare rules. The records show that a positioning pillow is already approved and 
are inclusive. The records also show that a foot platform has a code and is miscoded in this request. A custom 
headrest cover does not serve a medical need and cannot be covered by the Plan. Although there 
are two requested power options on this wheelchair (tilt and elevating leg rests), there is not a medical need to 
control these power options through the joystick. Based on this information, we decided that Medicare rules for 
coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a positioning cushion/pillow (E0190), a power articulating foot platform (K0108), a custom 
headrest cover (K0108) and an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gastrointestinal tract imaging (91110). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that they had a colonoscopy to evaluate 
for bleeding within the past 12 months. The Plan states the colonoscopy was in February 2021 for screening. 
 
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 service. Our physician reviewer 
found the record indicates that the enrollee has iron deficiency anemia from suspected gastrointestinal bleeding. 
The record indicates that the enrollee had a colonoscopy over 12 months ago. 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the gastrointestinal tract imaging (91110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 12, 2022, to February 15, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, there was no clinical or laboratory evidence of respiratory failure. The records did not support 
the use of diagnosis code J96.01 - acute respiratory failure with hypoxia - in this case. DRG 872 is the 
appropriate DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from February 12, 2022, to February 15, 2022.