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

 
We decided that the Plan does not have to pay for a popliteal block provided to the enrollee on January 18, 
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 Current Procedural Terminology (CPT) code 64445-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
enrollee had ankle surgery performed under general anesthesia. She had a popliteal block via catheter placed 
for post-operative pain relief. There is no documentation of a separate consultation from the surgeon for this 
procedure. Therefore, the coding is incorrect. 
 
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 a popliteal block provided to the enrollee on January 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0426) and 
ground mileage (A0425) provided on March 27, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
it was medically necessary for the enrollee to be transported by ambulance. The Plan denied your request. The 
Plan says the absence of clinical information, medical necessity and coverage cannot be determined. The Plan 
also says with the information provided, it cannot be determined how the member came to the servicing 
provider, or whether the services were 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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the ambulance transport on March 27, 2022 was not 
medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation did not 
support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of 
vehicle) were contraindicated for this enrollee. Our reviewer also found that the documentation did not support 
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance could provide for safe transport on March 27, 2022. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0426) and ground mileage (A0425) provided on March 27, 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 you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says admission to IRF was 
denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. 
Skilled nursing facility level of care was offered. 
 
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 are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not 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. 
 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 the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 the home ventilator. Our physician 
reviewer found Medicare does not cover a home ventilator when used as bilevel positive airway pressure 
(BiPAP). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine 
(72148). 
 
You asked the Plan to pre-approve an MRI scan of the lumbar spine. You say that the requested procedure is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that medical-necessity rules for 
the requested procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI scan of the lumbar spine. Our 
reviewer says that the requested procedure is medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has trialed oral medications and most recently had an epidural steroid injection 
(ESI) with incomplete relief of symptoms. The enrollee has failed back syndrome. Due to the recent ESI 
procedure and incomplete resolution of symptoms, the enrollee qualifies for an MRI scan without a 6-week 
trial of physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan of the lumbar spine have been met. Therefore, we decided that the 
Plan has to pre-approve an MRI scan of the lumbar spine (72148).  
 
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 Prodigy Glucometer Test Strips. 
 
You asked the Plan to pre-approve Prodigy Glucometer Test Strips. You say that you do not administer these 
test strips. You live in an assisted living facility and the nurse administers the tests. The Plan denied your 
request. The Plan says you do not meet the criteria for coverage for a non-preferred diabetic supply. You can 
switch to one of the preferred products. 
 The Plan must follow Medicare rules. Medicare rules say that you must obtain diabetic testing supplies from 
Durable Medical Equipment (DME) suppliers. 
 
We looked at the file and Medicare rules. The EOC confirms that you must obtain diabetic supplies from a 
DME supplier. Testing supplies are covered using a preferred product. Based on this information, we decided 
that Medicare rules for coverage of Prodigy Glucometer Test Strips have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Prodigy Glucometer Test Strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. 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 LTACH services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99153) provided on June 15, 2021. 
 
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for Technical Component (TC) services furnished in institutional settings where the TC service is 
bundled into the facility payment, e.g., hospital inpatient and outpatient settings. The rules also say that a Professional Component (PC)/Technical Component (TC) Indicator of 3 denotes technical component only 
codes. 
 
We looked at the file and Medicare rules. Code 99153 has a PC/TC indicator of 3 and was billed in an inpatient 
setting. Based on this information, we decided that Medicare rules for coverage of sedation services have not 
been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided on 
June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information 
provided did not indicate that the Plan's Step Therapy criteria was met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Prolia. have been met. Medical records 
were not provided with this case. The record shows that the Plan made several attempts to obtain medical 
records, but they were not provided. Without this information, we are unable to determine if Prolia is medically 
reasonable and necessary and if the criteria for coverage are met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested supplies are a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram extended monitoring (95812, 95813) 
billed for date of service March 2, 2021. 
 
You asked the Plan to pay for electroencephalogram extended monitoring. You say that you have provided 
records to support the services at issue. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 95812 is "Electroencephalogram (EEG) extended 
monitoring; 41-60 minutes"; and of code 95813 is "Electroencephalogram (EEG) extended monitoring; 61-119 
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 electroencephalogram extended monitoring. Our reviewer 
says that the billed codes do not meet criteria for payment. Our reviewer found that there are more appropriate 
procedure codes to report for the procedures documented. CPT codes 95812 and 95813 cannot be verified in 
this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electroencephalogram extended monitoring have not been met. Therefore, we 
decided that the Plan does not have to pay for electroencephalogram extended monitoring (95812, 95813) 
billed for date of service March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gradient compression wrap (CPT code A6545). 
 
You asked the Plan to pre-approve the gradient compression wrap. You say that the gradient compression wrap 
is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the gradient compression wrap have not been met. The enrollee 
does not have documentation of a qualifying wound requiring treatment. Therefore, we decided that the Plan 
does not have to pre-approve the gradient compression wrap (CPT code A6545).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 96372 and the x-ray services 
coded 73630 provided on April 24, 2022. 
 
You asked the Plan to pay for the injection services and the x-ray services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 We find that CPT codes 96372 and 73630 are not supported in the medical record. Specifically, code 99284 
(emergency department visit) was billed on the same date of service, with revenue code 450. This code has a 
status indicator of "V". Therefore, this makes codes 73630 and 96372 not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the injection services and the x-ray services have 
not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 96372 
and the x-ray services coded 73630 provided on April 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 16, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria 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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has malignant neoplasm of 
the lower lobe, right bronchus or lung. The medical oncology note dated March 15, 2022 documents recently-
diagnosed anal cancer (squamous cell carcinoma), stage to be determined. The clinical documentation does not 
include a diagnosis of either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
has not been previously tested with the same test using NGS for the same cancer genetic content, and has 
decided to seek further cancer treatment. The services were therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Axolotl and Palingen wound coverings. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diabetic foot ulcer. 
He has evidence of poor lower extremity arterial circulation. The requested Axolotl and Palingen wound 
coverings do not currently have sufficient high quality evidence to support their regular use compared to more 
proven therapies. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Axolotl and Palingen wound coverings.