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

 
We decided that the Plan does not have to pay for procedure codes 33249 and 33225 provided on June 24, 
2022. 
 
You asked the Plan to pay for procedure codes 33249 and 33225. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 33249. As the primary procedure code, 33249, is not covered, the add-on code, 
33225, is also not covered. 
 
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 33249 is Insertion or replacement of permanent 
implantable defibrillator system, with transvenous lead(s), single or dual chamber. 
 
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 procedure code 33249. Our reviewer says that the medical 
records do not support the billing of code 33249. Our reviewer found the documentation submitted consists of 
pre and post procedural evaluations and flow sheets. There is no procedure report for the insertion or 
replacement of a permanent implanted defibrillator system. It cannot be verified that this procedure was 
performed during the encounter in question. 
 
Additionally, as the primary procedure code 33249 is not covered, the add-on code of 33225 is also not 
covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 33249 and 33225 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 33249 and 33225 provided on June 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that after your procedure you have not been able to put 
pressure on your foot. You need IRF services in order to be able to walk independently. The Plan denied your 
request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 support necessity for admission to an IRF and the 
complexity of your nursing, rehabilitation, and medical needs do not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While you may benefit from 
physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be provided in a lower 
intensity and alternate setting such as in a skilled nursing facility (SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on August 
17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the decision making was of moderate 
complexity. The Plan denied your request. The Plan says non-urgent services should be from network 
providers. 
 
 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 file shows that the enrollee presented with flank pain, determined to be constipation. 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the evaluation and management services provided on August 17, 2022, by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) for lymphedema 
assessment (93702 x 4). 
 
You asked the Plan to pre-approve BIS assessments. You say that the requested testing is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested testing is considered investigational 
and 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 BIS assessments. Our reviewer says 
that the requested BIS assessments are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee is at high risk for developing 
lymphedema. The reviewer found that current literature have not shown high quality studies showing a 
clinically significant benefit over standard monitoring methods for lymphedema to justify this testing. 
Therefore, the request for bioimpedance spectroscopy (BIS) for lymphedema assessments will be considered 
not medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BIS assessments have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bioimpedance spectroscopy (BIS) for lymphedema assessment (93702 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
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 there is not enough medical proof that shows the safety and/or success of 
this treatment, so it is considered experimental and/or unproven. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of genicular nerve blocks and of radiofrequency ablation (RFA) in the treatment of 
knee osteoarthritis is still the subject of ongoing clinical trials. Therefore, the request is deemed not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance 
(64624).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the urological supplies provided from April 25, 2022, to August 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that this is not a bundled code. The Plan denied your 
request. The Plan says that this charge is incidental to another service. 
 
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 code A4351 is supported. Code A4351 is not considered a bundled or packaged service 
under the durable medical equipment fee schedule. Based on this information, we decided that Medicare rules 
for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for the 
urological supplies provided from April 25, 2022, to August 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle sensor kit. 
 
You asked the Plan to pre-approve the Freestyle sensor kit. The Plan denied your request. The Plan says that 
the coverage criteria has not been met. 
 
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 you do not use insulin with at least 
three daily injections and do not 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 the Freestyle sensor 
kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle sensor kit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the proprietary laboratory analyses (0312U) provided June 
22, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please see the attached documents and below 
information regarding the test that was deemed medically necessary by the enrollee's physician. The Plan 
denied your request. The Plan says this service does not meet the requirements and is excluded from coverage. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence 
to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollees conditions. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the proprietary laboratory analyses (0312U) provided June 22, 2022.
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 does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for surgical repair of a distal femur fracture after a fall. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. 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. Medically necessary 
care can be provided in a different level of care. 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you are appealing with records. The Plan denied your 
request. The Plan says the Plan requires a trial of zoledronic acid before it will approve Prolia. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Prolia. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Prolia. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of zoledronic acid. The record does not show that this 
drug would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a drop-arm bariatric commode chair (E0165). 
 
You asked the Plan to pre-approve a commode chair. You say that the enrollee needs this item. The Plan denied 
your request. The Plan says the requested drop-arm commode is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a commode chair with detachable arms is covered if 
the detachable arms feature is necessary to facilitate transferring the beneficiary or if the beneficiary has a body 
configuration that requires extra width. If coverage criteria are not met payment will be denied as not 
reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a commode chair. Our reviewer says 
that a drop-arm commode chair is not medically necessary. Our physician reviewer found the provided 
documentation does not support that the enrollee is physically incapable of utilizing regular toilet facilities. 
Therefore, the reviewer found that the requested drop-arm commode chair 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 commode chair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a drop-arm bariatric commode chair (E0165).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 4, 2022, to May 
9, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.9, described as sepsis, 
unspecified organism. 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 documentation does not support the billed code. 
Our physician reviewer found the records did not support that there was evidence of significant hypoxemia, 
presence of a significant acute mental status change or significant renal or hepatic dysfunction beyond the 
patient's baseline to suggest a dysregulated host response to infection was present.  
 
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 May 4, 2022, to May 9, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the requested CGM and supplies are 
medically necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM and 
supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from acute rehab to optimize 
their level of functioning prior to returning home. You say that the enrollee has serious life-threatening medical 
problems which requires interdisciplinary therapy care. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met in alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.