Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64490, 64491). 
 
You asked the Plan to pre-approve the injections. You say that these 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 Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients with the absence of 
untreated radiculopathy or neurogenic claudication. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the requested facet joint injections are not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee has been diagnosed with radiculopathy. Therefore, the reviewer found 
that the requested injections are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64490, 64491).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869). 
 
You asked the Plan to pre-approve a Vertiflex Interspinous Process Distraction device. You say that this 
procedure provides decompression of the spine using an implant that is placed via a small incision, under local 
anesthesia. You also say the implant then holds the space open, preserving the space in the spine necessary to 
lift the pressure off the nerves and lower back. There is no removal of the bone or muscle and soft tissue 
dissection. You plan to provide this procedure on an outpatient basis specifically in the ambulatory surgery 
center. The Plan denied your request. The Plan says the service or item in question is not covered under the 
enrollee's contract under any normal circumstances. In addition, the requested service is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Interspinous Process 
Distraction device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found interspinous process distraction devices are 
experimental and investigational in cases of spinal surgery. 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 a Vertiflex Interspinous Process Distraction device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement regarding payment between the dialysis facility and the laboratory. The Plan denied your request. 
The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 20, 
2022.
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 the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 was recently hospitalized 
for exacerbation of COPD and heart failure.  ABGs were consistent with acute on chronic hypercarbic 
respiratory failure. There are no PFTs to assess the severity of the COPD. BiPAP was used in the hospital. 
There is no evidence that BiPAP with AVAPS has been tried as an outpatient. Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (Vertiflex device) (22869). 
 
You asked the Plan to pre-approve Vertiflex device. You say that the requested service is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested service 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 Vertiflex device. Our reviewer says that 
the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested Vertiflex device is considered experimental. therefore, the reviewer found that the 
requested device is 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without 
open decompression or fusion, including image guidance when performed, lumbar; single level (Vertiflex 
device) (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 49566 is 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 49566 is repair recurrent incisional or ventral hernia; 
incarcerated or strangulated. 
 
We find that CPT code 49566 is not supported in the medical record. Specifically, the records show that an 
open repair of an incarcerated hiatal hernia was performed and there is a more appropriate code for these 
services. 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 pay for the surgical services rendered on May 
22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 5, 2022 to 
March 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 5, 2022 to March 
30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845). 
 
You asked the Plan to pre-approve a knee stance flexion feature. You say that the requested addition is 
necessary for the enrollee. The Plan denied your request. The Plan says the requested part is unbundled from 
the approved knee and cannot be requested separately. The requested part is not medically necessary and not 
paired with L5812. 
 
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 knee stance flexion feature. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is approved with a prosthesis with a stance phase control. The 
provider has not provided evidence in support of the medical necessity for the L5845 addition for a person who 
is a K2 ambulator. Per Medicare, the additions must have sufficient documentation in support of medical 
necessity. The provider and prosthetist have not supplied evidence of medical necessity for the L5845 addition. 
 
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 knee stance flexion feature have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845).
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 the device is medically necessary due to 
bronchiectasis. The Plan denied your request. The Plan says the details they got from your doctor do not meet 
Medicare guidelines that show a medical reason you need the requested system. The request has been denied as 
the medical necessity criteria have not been met. 
 
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 
service is not medically necessary. Our physician reviewer found you have respiratory symptoms including 
cough and were recently diagnosed with non-small cell lung cancer. Bronchiectasis is listed on some problem 
lists from the hospital stay, but a CT chest on 11/28/2022 does not mention bronchiectasis. There is no 
documentation of difficulty raising secretions. There is no diagnosis of cystic fibrosis or neuromuscular 
disease. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve the repeat injection. You say that the enrollee has severe pain that radiates 
down their legs. You also say that she needs her pain shots. The Plan denied your request. The Plan says the 
requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief for 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 the repeat injection. Our reviewer says 
that a repeat injection is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the previous epidural steroid provided at least 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline using same scale for at least three (3) months. 
Therefore, the reviewer found that a repeat ESI 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 repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 1, 2022, to 
August 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
August 1, 2022, to August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Interfyl, arthrocentesis, aspiration and/or injection, 
intermediate joint or bursa without ultrasound guidance, arthrocentesis, aspiration and/or injection, 
intermediate joint or bursa with ultrasound guidance, injections, fluoroscopic guidance for needle placement, 
and ultrasonic guidance for needle placement. 
 
You asked the Plan to pre-approve Interfyl, arthrocentesis, aspiration and/or injection, injections, fluoroscopic 
guidance for needle placement, and ultrasonic guidance for needle placement. You say that this product is not 
being used in clinical trials, medical research study, or a program requiring the approval. You also say that you 
would like the denial to be reconsidered. The Plan denied your request. The Plan says there is no published 
literature on the effectiveness of Interfyl injection in the knee to treat heel pain. The Plan also says the Plan's 
medical policy and guidelines consider this product unproven and not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 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 Interfyl, arthrocentesis, aspiration 
and/or injection, injections, fluoroscopic guidance for needle placement, and ultrasonic guidance for needle 
placement. Our reviewer says that Interfyl is not reasonable and necessary for the enrollee. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of heel and foot pain. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer 
found that the Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested service cannot be 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 Interfyl, arthrocentesis, aspiration and/or injection, injections, fluoroscopic 
guidance for needle placement, and ultrasonic guidance for needle placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Interfyl, arthrocentesis, aspiration and/or injection, 
intermediate joint or bursa without ultrasound guidance, arthrocentesis, aspiration and/or injection, 
intermediate joint or bursa with ultrasound guidance, injections, fluoroscopic guidance for needle placement, 
and ultrasonic guidance for needle placement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018) and replacement supplies and accessories for external upper limb tremor 
stimulator of the peripheral nerves of the wrist (K1019). 
 
You asked the Plan to pre-approve the Cala Trio therapy system. You say that services are medically necessary. 
The Plan denied your request. The Plan says the Cala Trio therapy system and monthly supplies requested does 
not meet the requirements for approval. 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 the Cala Trio therapy system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member. There is insufficient evidence in the literature to support the use of this device for essential tremor. 
The requested device is not the standard of care for essential tremor and 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 Cala Trio therapy system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist 
(K1018) and replacement supplies and accessories for external upper limb tremor stimulator of the peripheral 
nerves of the wrist (K1019).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 26, 2021 
to December 5, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
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 A41.51. 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 use of diagnosis code A41.51 is not supported by the records provided. Our physician 
reviewer found that the enrollee presented to the facility on November 26, 2021 with shortness of breath. Her 
vital signs in the emergency room noted a temperature of 97.9, a pulse 102, a respiratory rate of 18, a blood 
pressure of 106/48, and a SpO2 of 97% on room air. The enrollee was in no acute distress and was alert and 
oriented to person, place, time, and situation. Initial laboratory data revealed a white blood cell count of 13.4 
and a hemoglobin of 6.3. The enrollee was admitted to the ICU with symptomatic anemia and to rule out a 
gastrointestinal bleed. Gastroenterology was consulted and the EGD noted ulcers in the duodenal bulb which 
was treated with hemostatic spray and a Protonix drip. While the enrollee was also found to have a urinary tract 
infection and documentation indicated a diagnosis of sepsis, the clinical evidence did not support the condition.  
 
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 November 26, 2021 to December 5, 2021, at the Diagnosis Related 
Group (DRG) originally billed.