Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says criteria for admission 
to the Acute Inpatient Rehabilitation setting have not been met. 
 
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 there is not a reasonable expectation that the 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: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary and supported by 
strong science. The Plan denied your request. The Plan says studies have not proven that this is helpful 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed to show safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says that the member does not meet the Medicare criteria for an IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee does require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a 
week, or 15 hours over seven consecutive days. The enrollee requires moderate assistance with toileting, 
maximum assistance with showering, supervision with bed mobility, moderate assistance with transfers and 
supervision to contact guard assistance when ambulating 100 feet with a walker. The enrollee has had a 
significant decline from the baseline level of function and would benefit from the intensity of therapies 
provided on acute inpatient rehabilitation. The enrollee is also noted to have dysphagia and would benefit from 
speech as well as occupational and physical therapies. Therefore, the acute inpatient rehabilitation admission is 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95913) provided on August 10, 
2022. 
 
You asked the Plan to pay for the services. You say that the necessary medical documentation was included to 
support the service and procedure performed. The Plan denied your request. The Plan says charges for in 
connection with services or supplies that are considered to be experimental or investigational are excluded from 
coverage under the enrollee's plan. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record indicates that the enrollee has known neuropathy in the setting of chemotherapy. The 
provided records are insufficient to establish the medical necessity of the requested service. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied.  
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 pay for the nerve conduction studies (95913) provided on August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on September 
11, 2022. 
 
You asked the Plan to pay for the chest x-ray interpretation. You say that these claims are not duplicate. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 29, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the 
same date. Based on this information, we decided that the Medicare rules for the chest x-ray interpretation have 
not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the chest x-ray 
provided on September 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positional rotation unit (K1022) for a lower-extremity 
prosthesis. 
 
You asked the Plan to pre-approve a positional rotation unit. You say that the requested item is 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 a positional rotation unit. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested device has not been shown to be superior to other standard treatments for the 
enrollee's medical condition. There is no indication that the requested device will improve the enrollee's 
function or general health.  
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 positional rotation unit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positional rotation unit (K1022) for a lower-extremity prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair 
(PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested power seat elevation feature is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature for a 
power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (64555) and an implantable neurostimulator, pulse generator (L8679). 
 
You asked the Plan to pre-approve Auricular Nerve Stimulator. You say that the enrollee is likely to obtain 
significant therapeutic benefits for the neurostimulator treatment which will eliminate/decrease localized and 
referred pain, improve clinical picture, significantly increase mobility without pain and muscle spasm 
relaxation. The Plan denied your request. The Plan says the requested stimulator does not fit the Medicare 
definition of an implanted peripheral nerve stimulator. 
 
The Plan must follow Medicare rules. The rules say that this service is not a covered Medicare benefit because 
acupuncture for auricular stimulation does not meet the definition of reasonable and necessary under Section 
1862(a)(1) of the Act. 
 
The records show that the Plan does not cover the requested stimulator for any reason. The stimulator does not 
meet NCD criteria for coverage. The NCD confirms that stimulation is induced by a generator connected to an 
antenna unit which is attached to the skin surface over the receiver unit. The records do not indicate that the 
device will be implanted with conduction surgery and/or anesthesia. Therefore, we decided that the Plan does 
not have to pre-approve a percutaneous implantation of neurostimulator electrode array; peripheral nerve 
(64555) and an implantable neurostimulator, pulse generator (L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary under certain conditions. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no evidence 
provided that would support the need for radionuclide stress testing. There is insufficient documentation to 
support the medical necessity for the requested cardiac stress testing in this enrollee's 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 myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incision and drainage of abscess (D7510) and bone 
replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve incision and drainage of abscess and bone replacement graft for ridge 
preservation. You say that these services are necessary. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
incision and drainage of abscess (D7510) and bone replacement graft for ridge preservation (D7953).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 77295, 77771, 77290 and 
77334. We decided that the Plan does not have to pay for the services described by procedure code 77300.  
 
You asked the Plan to pay for the services provided on December 15, 2021. You say that these services are 
supported in the medical record. The Plan says that the payment for code 77300 is included in the payment for 
code 77771. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 77295, 77771, 77290 
and 77334.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 77295, 77771, 77290 and 
77334.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 77300. 
 
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 code 77300 
is a column II code to column I code 77771 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 described by procedure code 77300. 
 
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 percutaneous vertebral augmentation 
 You asked the Plan to pre-approve percutaneous vertebral augmentation. The Plan denied your request. The 
Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is covered for 
the indications established in the applicable LCD. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that percutaneous vertebral augmentation is not medically reasonable and necessary in this 
case. Our physician reviewer found that detailed documentation is not evident regarding a trial and failure of 
recent, reasonable, comprehensive less invasive conservative care measures. Additionally, the documentation 
does not corroborate moderate to severe pain (NRS or VAS greater than or equal to 5) despite optimal non-
surgical management (NSM) with one of the following: worsening pain; or stable to improved pain (but NRS 
or VAS > 5) when two or more of the following are present: a) progression of vertebral body height loss, b) > 
25% vertebral body height reduction, c) kyphotic deformity, d) severe impact of vertebral compression fracture 
on daily functioning. Therefore, the requested percutaneous vertebral augmentation, in this case, 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 percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 83036 (A1c testing) billed for date of service December 
15, 2021. 
 
You asked the Plan to pay for code 83036. You say that you have submitted medical records to support 
payment. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 83036 is Hemoglobin; glycosylated (A1c). 
 
We find that CPT code 83036 is not supported in the medical record. The lab report explicitly states that the 
Hemoglobin A1c could not be performed because the lavender tube was not received.  Therefore, it is clear that 
this service was not provided. Based on this information, we decided that Medicare rules for coverage of code 
83036 have not been met. Therefore, we decided that the Plan does not have to pay for code 83036 (A1c 
testing) billed for date of service December 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of OrthoFix Trinity Elite allograft (20930). 
 
You asked the Plan to pre-approve OrthoFix Trinity Elite allograft. You say that the requested services is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 OrthoFix Trinity Elite allograft. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the OrthoFix Trinity Elite allograft is experimental in spine surgery. More 
research is needed to demonstrate its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OrthoFix Trinity Elite allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the use of OrthoFix Trinity Elite allograft (20930).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET); metabolic evaluation (78608).

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 PET scan of the brain. Our reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates that you have memory loss and cognitive decline associated with likely Alzheimer's disease. The record does not indicate that you meet diagnostic criteria for both fronto-temporal dementia and Alzheimer's disease or are enrolled in a clinical trial. 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 a PET scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET); metabolic evaluation (78608).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for procedure code 93971. You say that this should be paid as billed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93971 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93971 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93971 billed for date of service July 21, 2022.