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

 
We decided that the Plan does not have to pay for the electromyography (EMG) testing provided on April 8, 
2022, billed with code 51785. 
 
You asked the Plan to pay for the EMG testing as billed. You say that it is felt that code 51785 is supported and 
should be paid. The Plan denied your request. The Plan says the record does not support payment for this code. 
 
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 51785 is Needle electromyography studies (EMG) of 
anal or urethral sphincter, any technique. 
 
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 the EMG testing as billed. Our reviewer says that the records 
provided do not support the use of code 51785. Our reviewer found that for CPT code 51785, needles are 
placed in the pelvic floor muscles (external sphincter). The equipment demonstrates graphic recordings measuring EMG activity during a series of filling and voiding trials to evaluate pelvic floor activity. In this 
case, this procedure cannot be verified. The report does not include documentation that these services were 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the EMG testing as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the electromyography (EMG) testing provided on April 8, 2022, billed with code 
51785.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat ESI (CPT code 62323). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has pain and wants to avoid surgery. 
The Plan denied your request. The Plan says the record does not show that the enrollee had at least 50% 
improvement from the previous injection. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our physician reviewer 
found the LCD requires 50 percent pain relief for 3 months. This was not achieved and therefore, the request is 
deemed 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat ESI (CPT code 62323).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a K3 Ossur Pro-Flex foot. 
 
You asked the Plan to pre-approve a K3 Ossur Pro-Flex foot. You say that the enrollee qualifies for the 
requested foot because of his K3 activities and desire to continue with his active lifestyle. The Plan denied your 
request. The Plan says that the incorrect codes are being requested for coverage of a K3 Ossur Pro-Flex foot. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 K3 Ossur Pro-Flex foot. Our reviewer 
says that a K3 Ossur Pro-Flex foot is considered medically reasonable and necessary in this case. Our physician 
reviewer found a level 3 ambulator has the ability or potential for ambulation with variable cadence.  Typical of 
the community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. In this case, the 
requested prosthesis is indicated for a K3 level functional ambulator.  The documentation indicates the member 
has the potential for K3 level function. 
 
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 K3 Ossur Pro-Flex foot have been met. Please note that while the codes the 
provider used in their prior authorization request may be incorrect for the item(s) being requested, coding 
arguments should not be used to determine whether a requested service can or should be covered. As the 
provider is noted to be in-network, it is expected that the Plan would work with its provider to determine what 
codes are correct for a given service when its time to bill the claim. An enrollee should not be denied access to 
covered services due to the network provider requested non-covered or incorrect codes. Therefore, we decided 
that the Plan has to pre-approve a K3 Ossur Pro-Flex foot.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
provided on August 19, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you are requesting retroactive authorization 
and reimbursement for the non-emergent ambulance transport from the hospital to the nursing home. The Plan 
denied your request. The Plan says we require prior authorization for non-emergent ambulance services. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may require enrollees to obtain 
authorization before receiving services. The Plans contract states that prior authorization is required for non-
emergency transportation.  
 
There is no evidence of prior authorization having been requested or issued, and the medical records show the 
ambulance services provided were non-emergent. Based on this information, we decided that Medicare rules 
for coverage of the ambulance service, basic life support, emergency transport have not been met. Therefore, 
we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the catheter placement in coronary artery(s) for 
coronary angiography (CPT code 93458). 
 
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 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient documentation to support the medical necessity of cardiac catheterization 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the catheter placement in coronary artery(s) for coronary angiography (CPT code 93458).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for periodontal maintenance (D4910) provided on June 9, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you did have this service previously 
which was rendered on your last filed claim submitted. You also say that the service was not done twice in 
twelve (12) continuous months. The Plan denied your request. The Plan says that the reported service is limited 
to two (2) in a twelve (12) continuous month period. Benefits have been provided previously for this service 
within the time period. 
 
The Plan must follow Medicare rules. Medicare rules say that for a service or item that could be covered under 
some conditions, the EOC alone is not adequate of non-coverage. If no notice of non-coverage is given, the 
enrollee is held harmless.  
 
We looked at the file and Medicare rules. You were referred for periodontal maintenance services by a contract 
provider. This is a service that could be covered under some conditions, according to the Plans supplemental 
dental benefits. The Plan contract says one exam and cleaning is allowed every six months in some instances. 
Specifically, the file does not show that the Plan provided notice that periodontal maintenance would not be 
covered. Under Medicare rules, this means that the periodontal maintenance is considered approved by the 
Plan. Based on this information, we decided that Medicare rules for coverage of periodontal maintenance  have 
been met. Therefore, we decided that the Plan has to pay for periodontal maintenance (D4910) provided on 
June 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat ESI (CPT code 62321). 
 
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 the injection. Our physician reviewer 
found the LCD criteria is 50 percent pain relief for 3 months. This was not achieved and therefore, the request 
is deemed 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 the injection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a repeat ESI (CPT code 62321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism provided on March 17, 2022. 
 
You asked the Plan to pay for the seat lift. You say that you believe that this is medically necessary for your 
safety in the home. The Plan denied your request. The Plan says the criteria for this item are not met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift. Our reviewer says that the 
Medicare coverage criteria for the seat lift mechanism are not met in this case. Our physician reviewer found 
the enrollee has grade 1 spondylolisthesis and some moderate foraminal stenosis. He does not have arthritis of 
hip or knee reported. Without documentation of neuromuscular disease or arthritis of the knee or hip, criteria 
for this lift are not met. 
 
 
 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 seat lift have not been met. Therefore, we decided that the Plan does not 
have to pay for the seat lift mechanism provided on March 17, 2022.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF admission is not shown to be 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may benefit from speech therapy, physical therapy and occupational therapy, the enrollee's rehab 
needs can be provided in a lower intensity and alternate setting. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you are 
type 2 diabetic and have to test yourself frequently. The Plan denied your request. The Plan says you do not 
require insulin three or more times daily. 
 
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 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the medical records provided support the 
need for the requested device. The Plan denied your request. The Plan says the requested home mechanical 
ventilator would be set in intelligent volume-assured pressure support (iVAPS) mode with auto- expiratory 
positive airway pressure (EPAP) that could be delivered by bi-level positive airway pressure (BiPAP) and is 
therefore non-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 criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic 
obstructive pulmonary disease (COPD) and was recently hospitalized with an exacerbation.  Arterial blood gas (ABG) showed acute on chronic hypercarbic respiratory failure.  There are no pulmonary function tests (PFTs) 
to assess severity of the COPD, and no ABG done while stable to document chronic carbon dioxide (CO2) 
retention.  If this patient does have severe COPD with chronic CO2 retention, may benefit from BiPAP with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for nonadjunctive, nonimplanted 
continuous glucose monitor (CGM), includes all supplies, accessories, and receiver (A4239, E2103). 
 
You asked the Plan to pre-approve a CGM with supplies, accessories, and receiver. You say that you have used 
the requested CGM for almost a year and was approved for it with your last insurance company. The Plan 
denied your request. The Plan says you do not meet the requirement for approval of the requested CGM and 
supplies. 
 
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 perform blood glucose 
testing at least four times per day, 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 with supplies, accessories and receiver have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a supply allowance for nonadjunctive, 
nonimplanted continuous glucose monitor (CGM), includes all supplies, accessories, and receiver (A4239, 
E2103).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health 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 pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether the requested authorization for placement of an ILR is medically appropriate and 
necessary. There is no documentation provided to suggest a history of unexplained syncope 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 patients 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 15004) provided to the 
enrollee on August 19, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 15004 is "Surgical preparation or creation of recipient 
site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of 
scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 
100 sq cm or 1% of body area of infants and children." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does not 
meet the criteria for surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar or inciional release of scar contracture. 
 
We looked at this coder'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 surgical services (procedure code 15004) provided to the enrollee on August 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on August 20, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the enrollee met the medical necessity, in addition to having a prior authorization for this trip. The Plan denied 
your request. The Plan says the transport does not meet criteria as it was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the transportation via ambulance from the enrollee's dialysis 
appointment was not medically necessary.  
Our physician reviewer found the enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transport could have been provided by 
other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on August 20, 2022.