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

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99407 provided to the enrollee 
from April 10, 2022, to April 12, 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 service is not supported without the required documentation. 
 
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 the denied codes is: 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
CPT 99407: 
 
Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 
 
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 Our reviewer found that the medical records demonstrate that medical decision making was 
straightforward, and not complex. There would be a more appropriate code to use than CPT 99233. In terms of 
CPT 99407, the medical records do not include any documentation of smoking and tobacco use cessation 
counseling visit; intensive, greater than 10 minutes. 
 
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 procedure codes 99233 and 99407 provided to the enrollee from April 10, 2022, to April 12, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested Evenity is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Ibandronate, Pamidronate, or Zoledronic 
Acid first. 
 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 Evenity. Our reviewer says that the 
Plan's step therapy criteria not been met. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Ibandronate, Pamidronate, or Zoledronic acid. The documentation does 
not support that Ibandronate, Pamidronate, or Zoledronic Acid would likely be less effective, and/or would 
likely have adverse effects for the enrollee 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 1 standard, 
patient weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a POV. You say that you find it hard to move around with your walker. You 
have knee and back problems and would like to have this POV to go to the grocery store. You have arthritis 
and going to the store is difficult with a walker. The scooter will help you to be more independent. You would 
feel safer with a scooter versus a walker. The Plan denied your request. The Plan says you are ambulating 
within the home with a four wheeled walker. You report the need for an electric scooter for shopping and going 
to the clubhouse. You do not meet the criteria for a scooter or power chair. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (POV), group 1 standard, patient weight capacity up to and 
including 300 pounds (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist hand orthosis, includes one or more nontorsion 
joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf (L3916) 
provided on October 4, 2022. 
 
You asked the Plan to pay for a wrist hand orthosis. You say that the attached records confirm the script from 
the enrollee's primary care provider along with chart notes from a face-to-face visit within the last six months. 
You have also attached the packing slip and proof of delivery to reprocess the claim for payment. The Plan 
denied your request. The Plan says there is no mention of the braces in the referring physician records received 
with the appeal. A prescription is not considered to be part of the medical record.  
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records also do not show mention of the braces in the referring physicians records with 
previous office visits. Therefore, we decided that the Plan does not have to pay for a wrist hand orthosis, 
includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, 
prefabricated, off-the-shelf (L3916) provided on October 4, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve Gamunex-C. You say that the requested Gamunex-C is medically necessary. 
The Plan denied your request. The Plan says that the requested Gamunex-C is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gamunex-C. Our reviewer says that the 
requested Gamunex-C is medically necessary. Our physician reviewer found the requested use of Gamunex-C 
is FDA-approved for the enrollee's diagnosis. The documentation supports that the requested drug is safe and 
effective and otherwise reasonable and necessary for this 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 Gamunex-C have been met. Therefore, we decided that the Plan has to pre-
approve Gamunex-C.  
 
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 procedure code 70450 billed for date of service May 12, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute product to act as wound barrier (Revita). 
 
You asked the Plan to pre-approve Revita. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are 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 Revita. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has nodular basal cell carcinoma of the scalp. The enrollee underwent Mohs 
surgery; however, the wound has now dehisced leaving a large ulcer. The enrollee has since underwent 
debridement and general wound care. The documentation described the wound to be 3 x 2 cm on January 9, 
2023, and 3 x 1.9 cm on January 26, 2023, without signs of infection. The provided documentation does not 
show significant evidence of failure of standard wound care not being effective for this enrollee as only a few 
weeks had passed following initiation of debridement and general wound care treatment with some slight, 
although noted improvement in the size of the wound. A longer duration trial of more conservative treatments 
would be needed to determine if the enrollee was failing standard care before grafting should be considered. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Revita have not been met. Therefore, we decided that the Plan does not have to 
pre-approve skin substitute product to act as wound barrier (Revita).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve implantation of a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are 
experimental/investigational. 
 
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 CardioMEMS device. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that CardioMEMS shows the most benefit in patients with Class III heart failure and some 
patients with Class IV heart failure. Implantation of a CardioMEMS device for remote hemodynamic 
monitoring has been determined to be appropriate 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 a CardioMEMS device have been met. Therefore, we decided that the Plan has 
to pre-approve implantation of a CardioMEMS device (33289).  
 
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 of the lumbar 
spine (22514). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the requested services 
are 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 percutaneous vertebral augmentation. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee may have multiple myeloma that has not been diagnosed. 
Also, there is no evidence that the fractures are fewer than 6 weeks old. There is no documentation of a bracing 
trial. 
 
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 of the lumbar spine (22514).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary due to the enrollee's 
medical condition. The Plan denied your request. The Plan says that the request is not covered by Medicare. 
 
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 requesting provider is a contracted plan provider. No records were sent in 
by this provider. As this provider is contracted, it is the plan's responsibility to request these records. There is 
no evidence in the case file that records were requested for this case. Therefore, we decided that the Plan has to 
pre-approve home health 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special supplemental benefit for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no documentation that you meet criteria of the requested benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we have confirmed that you do not have one of the eligible 
conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-
approve a special supplemental benefit for the chronically ill (SSBCI).
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this enrollee does not have complex medical or intensive rehabilitation 
needs requiring supervision by a rehabilitation physician and an intensive and coordinated interdisciplinary 
team in a resource intensive inpatient hospital environment. The therapy required for the enrollee is not therapy 
that is uniquely provided in an IRF. This enrollee does not have complex nursing or medical needs requiring a 
resource intensive inpatient hospital setting. 
 
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 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device. 
 
You asked the Plan to pre-approve a Cala Trio nerve stimulator device. You say that the requested Cala Trio 
nerve stimulator device is medically necessary. The Plan denied your request. The Plan says the requested Cala 
Trio nerve stimulator device 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 Cala Trio nerve stimulator device. 
Our reviewer says that the requested Cala Trio nerve stimulator device is not medically necessary. Our 
physician reviewer found the enrollee has a diagnosis of essential tremor. The case file contains a letter from a neurologist stating that the enrollee has essential tremor which is medically refractory and interferes with 
activities of daily living. No medical records are submitted. There is insufficient documentation supporting that 
the Cala Trio nerve stimulator device is medically reasonable and necessary for the enrollee in this case. In 
addition, the available published studies do not demonstrate clinical benefit beyond 3 months, and do not 
compare the device to other treatment options. 
 
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 Cala Trio nerve stimulator device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Cala Trio nerve stimulator device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 76770. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76770 is bundled into payment for code 
76705. 
 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 76770 
is a column II code to column I code 76705. 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 code 76770 billed for date of service October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) 
procedure. 
 
You asked the Plan to pre-approve a MILD procedure. You say that the requested MILD procedure is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested MILD procedure. 
 
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 MILD procedure. Our reviewer says 
that the enrollee does not meet criteria for the requested MILD procedure. Our physician reviewer found the 
enrollee is diagnosed with lumbar spinal stenosis (LSS) with neurogenic claudication (NC). The MILD 
procedure is experimental for spinal stenosis. More research is needed at this time. The records do not show 
that the enrollee is enrolled in an approved clinical study. 
 
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 MILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that you have had crutches and a walker, but 
because of your age and your arthritis, it does not make sense to hop around on your non-dominant leg. You 
also say that your left ankle is weakening, and you cannot work with crutches or a walker. The Plan denied 
your request. The Plan says the requested item is not covered by Medicare or the Plan. 
 
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. A crutch substitute does not meet the program's requirements for 
Medicare coverage. There is insufficient published clinical literature demonstrating safety and effectiveness in 
the Medicare population to establish the medical necessity for these products. Based on this information, we 
decided that Medicare rules for coverage of a crutch substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without wheels (E0118).