Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 9, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted, and the proof 
of delivery is not itemized to indicate the specific supplies. 
 
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. The Plan argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted, and the proof of delivery is not itemized to indicate the 
specific supplies. However, the records contain an itemized packing slip dated September 9, 2022, with the 
same tracking number as the delivery ticket dated September 13, 2022. As such, the records support that the 
items at issue in this case were delivered. Therefore, we decided that the Plan has to pay for the electrical 
stimulator supplies provided on September 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had a recent amputation, needs wound 
care, and will be taking 2 antibiotics. The Plan denied your request. The Plan says the enrollee does not meet 
all the Medicare criteria for admission to an IRF. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement. However, the documentation does not support that the enrollee would meet criteria for 
admission to an IRF. There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours per week, under the supervision of a physician with at least 3 
visits weekly, to regain or maintain their functional status. The enrollee can receive further services at a lower 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the transcutaneous electrical nerve stimulation (TENS) device (E0730) 
provided on September 28, 2022. 
 You asked the Plan to pay for the TENS device. You say that this claim was billed correctly. The Plan denied 
your request. The Plan says that the documentation does not include a proof of delivery or a delivery ticket. 
 
The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 
We looked at the file and Medicare rules. The record does contain a valid proof of delivery. The TENS device 
is supported by the records provided because the packing slip and the third-party delivery tracking information 
have a tracking number to link those documents together. The documents mee the Medicare rules for valid 
proof of delivery. Based on this information, we decided that Medicare rules for coverage of the TENS device 
have been met. Therefore, we decided that the Plan has to pay for the transcutaneous electrical nerve 
stimulation (TENS) device (E0730) provided on September 28, 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: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 3, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted, and the proof 
of delivery is not itemized to indicate the specific supplies. 
 
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. The Plan argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted, and the proof of delivery is not itemized to indicate the 
specific supplies. However, the records contain an itemized packing slip dated September 3, 2022, with the 
same tracking number as the delivery ticket dated September 12, 2022. As such, the records support that the 
items at issue in this case were delivered. Therefore, we decided that the Plan has to pay for the electrical 
stimulator supplies provided on September 3, 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 intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve intraosseous ablation of the basivertebral nerve. You say that intraosseous 
ablation of the basivertebral nerve is medically necessary. The Plan denied your request. The Plan says 
intraosseous ablation of the basivertebral nerve 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 intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the requested intraosseous ablation of the basivertebral nerve is not 
considered medically reasonable and necessary. Our physician reviewer found that the Intracept procedure 
targets the basivertebral nerve for the relief of chronic verterbrogenic low back pain.  Medicare guidelines 
consider this type of system unproven and not medically necessary. Large, well-designed studies in the peer 
review scientific literature comparing stand-alone use of Intracept device to established surgical decompression 
are needed. Published studies do not demonstrate any long-term health outcome advantage with the use of 
Intracept as an alternative to standard surgical treatment. The review has determined that the requested 
intraosseous ablation of the basivertebral nerve is not medically reasonable or necessary in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraosseous ablation of the basivertebral nerve have not been met. Therefore, 
we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37765-LT billed for November 4, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery are included in the global surgical package. 
 
We looked at the file and Medicare rules. Billed procedure code 37765-LT was billed within 10 days of minor 
surgical procedure 37765-LT performed on October 28, 2022. Payment for code 37765-LT billed on November 
4, 2022 is included in the global surgical package for the services on October 28, 2022. Therefore, we decided 
that the Plan does not have to pay for procedure code 37765-LT billed for November 4, 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 member meets the full criteria for an IRF 
admission. The Plan denied your request. The Plan says IRF services requested do not meet the requirements 
for approval. 
 
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 members nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member continues to have a need for skilled therapy; however, the member does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. The member can receive further services at a lower 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 inpatient rehabilitation facility (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 an acute inpatient rehabilitation is medically 
necessary. The Plan denied your request. The Plan says the criteria for an IRF admission has 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies or an intensive rehabilitation therapy program. While the medical record 
supports a need for skilled therapy, there is no documented need for intensive rehabilitation services. You can 
receive further services at a lower 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 inpatient rehabilitation facility (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 member requires specific therapy provided with 
IRF services. The Plan denied your request. The Plan says IRF services requested do not meet the requirements 
for approval. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies or an intensive rehabilitation therapy program. While the 
medical record supports a need for skilled therapy, there is no documented need for intensive rehabilitation 
services. The member can receive further services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided November 3, 2022. 
 
You asked the Plan to pay for the TENS device. You say that according to the prescription, the prescribing 
physician recommends an extended lifetime use of equipment as the enrollee is diagnosed with chronic pain 
and compromised mobility without the option for surgical correction. The Plan denied your request. The Plan 
says this device including supplies is not a Medicare covered benefit for chronic back pain. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pay for 
the transcutaneous electrical nerve stimulation (TENS) device (E0730) provided November 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet screw stabilization procedure to be performed at 
spinal levels L2-3 and L3-4. 
 
You asked the Plan to pre-approve the requested facet screw stabilization procedure. You say that this 
procedure would benefit the enrollee by reducing the level of pain. The Plan denied your request. The Plan says 
this procedure has not been proven safe and effective for this 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 requested facet screw stabilization 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found per the Food and Drug Administration (FDA), the 
requested procedure "is indicated for the posterior surgical treatment at C2-S1 (inclusive) spine levels for the 
following: Spondylolisthesis; spondylolysis; pseudoarthrosis or failed previous fusions which are symptomatic; 
degenerative disc disease as defined by back pain of discogenic origin with degeneration of the disc confirmed 
by history and radiographic studies and/or degenerative disease of the facet with instability. The system is intended for use with bone graft material." 
 
In this case, the enrollee is a 68-year-old male was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication. He presented with debilitating low back pain. He cannot walk, drive, sit, or stand 
without significant pain. However, detailed documentation is not evident regarding dynamic flexion/extension 
films to potentially assess the amount of movement (instability) at the requested surgical level. Detailed 
documentation is not evident regarding potential impending/inevitable temporary intra-operative 
instability. Moreover, the FDA does not support this procedure without the use of bone graft material. The 
request is not evident that a bone graft material is being requested. 
 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested L2-3 and L3-4 ION facet screw 
stabilization procedure in this case, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested facet screw stabilization procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a facet screw stabilization procedure to be performed at 
spinal levels L2-3 and L3-4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness exam provided on September 20, 2022. 
 
You asked the Plan to pay for the annual wellness exam. The Plan denied your request. The Plan says there 
were no emergency or urgent services rendered at the visit. There were in-network providers in the members 
area that could have performed the routine evaluation. There was no referral. There were no exceptions met 
that warranted a visit to an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service 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 an annual wellness exam provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says imaging 
studies have not ruled out radicular pain. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has lower back pain radiating down the left leg to the foot.  The enrollee has been treated with medications including opiates, physical therapy, exercises, and injections. In 
this case, there is documentation of radiculopathy. The records do not show that the requested treatment is 
indicated for 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798, and 87641, billed for date of 
service April 11, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87798, and 87641. The Plan denied your request. The 
Plan says payment for codes 87150, 87798, and 87641, is bundled.  
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87798 and 87641 are column 
II codes to column I codes and 87801 and 87150. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150, 87798, and 87641, billed for date of 
service April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code B4036 billed for date of service June 24, 2022, to July 
22, 2022. 
 
You asked the Plan to pay for code B4036. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for code B4036 is 1. The MAI value for this code is 1. You billed 27 units of this code, 
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code B4036 
have not been met. Therefore, we decided that the Plan does not have to pay for code B4036 billed for date of 
service June 24, 2022, to July 22, 2022.