Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee genicular nerve block. 
 
You asked the Plan to pre-approve left knee genicular nerve block. 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 left knee genicular nerve block. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for pain in the left knee. The enrollee 
presented with knee pain. The current pain score is six to seven out of 10 with right greater than left bilateral 
knee pain. The exam of the knees reveals right knee swelling. There is left knee swelling. Left knee tenderness 
of the medial joint line, lateral joint line, medial tibial plateau, and lateral tibial plateau. There is crepitus on left 
knee range of motion. However, there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to confirm the early positive findings regarding the safety and efficacy of the requested genicular nerve block 
as compared to other treatments for knee osteoarthritis. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 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 left knee genicular nerve block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve left knee genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in VAPS mode with or 
without Auto-EPAP (AE) that could be delivered by BiPAP is not 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 this item is not medically necessary. Our physician reviewer found The noted condition is not one for 
which the rules indicate that coverage is available for the requested service. Notwithstanding that fact, the 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. 
The plan has indicated coverage for such a device is available upon request. 
 
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 (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 30, 2021, 
to December 6, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records provided do not support the DRG rate submitted on this claim. The Plan denied your request. 
The Plan says these services were reported correctly and are supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with acute kidney failure with tubular necrosis (N17.0). 
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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that this diagnosis is not supported in the medical record. Our physician 
reviewer found that the enrollee presented to the emergency department with complaints of abdominal pain and 
depression. The enrollee had a past medical history of chronic obstructive pulmonary disease (COPD), 
hypertension, and atrial fibrillation. The emergency department physical exam noted that the enrollee was in no 
acute distress, had normal pulmonary effort, no respiratory distress, normal breath sounds, no focal 
neurological deficit, and was alert and oriented to person, place, and time. In this case, while it was noted that 
the provider diagnosed acute kidney failure with tubular necrosis (ATN), the clinical documentation does not 
sufficiently support this diagnosis. The review has determined that the records did not support the reporting 
of acute kidney failure with tubular necrosis (N17.0).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 30, 2021, to December 6, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in VAPS mode with Auto-
EPAP (AE) that could be delivered by BiPAP is not 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 member does not need this item. Our physician reviewer found the enrollee could be treated with a 
BiPAP machine with AVAPS capability. 
 
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 (E0466).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography, transthoracic (TTE), real-time with 
image documentation (93306) provided on November 28, 2021. 
 
You asked the Plan to pay for the TTE. You say that this should be reprocessed and paid as the provider is out 
of network. You also say that the claim was filed timely. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 26, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the 
echocardiography, transthoracic (TTE), real-time with image documentation (93306) provided on November 
28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA).  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the detailed documentation is not evident that the L5 burst fracture is acute or subacute. 
Additionally, the exam revealed neurological deficits. The magnetic resonance imaging (MRI) also 
demonstrated 5mm of osseous retropulsion of the posterior superior endplate as well as edema throughout the 
L5 vertebral body, approximately 50% vertebral body height loss, and severe right foraminal stenosis. These 
are all contraindications for the requested procedure. There is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. 
Further studies/testing is needed to corroborate this procedures safety and efficacy as compared to standard 
treatments. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 percutaneous vertebral augmentation (PVA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 78815 provided on January 31, 2022. 
 
You asked the Plan to pay for code 78815. The Plan denied your request. The Plan says the code is 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. In this case, we have confirmed that code 78815 
is a column II code to column I code 78816 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 78815 provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tolt Ability Drive (drive control, software and 
hardware), associated accessories, and Tobii mounting. 
 
You asked the Plan to pre-approve the Tolt Ability Drive, associated accessories, and Tobii mounting. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that An electronic interface that is used to allow lights or 
other electrical devices to be operated using the power wheelchair control interface must be billed with code 
A9270 (non-covered item). 
 
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 Tolt Ability Drive, associated 
accessories, and Tobii mounting. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found provided records do not document that the requested equipment is approved by the 
Food and Drug Administration or that the equipment meets Medicare criteria for safe and effective and 
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 Tolt Ability Drive, associated accessories, and Tobii mounting have not been met. Therefore, we decided that the Plan does not have to pre-approve the Tolt Ability Drive (drive 
control, software and hardware), associated accessories, and Tobii mounting.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (82570, 83986) provided on April 20, 2022. 
 
You asked the Plan to pay for validity testing. You say that this should be covered. The Plan denied your 
request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing (82570, 83986) provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hepatitis C antibody test (86803) provided on July 22, 
2022. 
 
You asked the Plan to pay for the hepatitis C antibody test. You say that this service should be covered. The 
Plan denied your request. The Plan says there was insufficient information provided to determine how the 
enrollee came to the servicing provider, whether the services are medically necessary, or whether the services 
were performed as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the hepatitis C antibody test have been 
met. Specifically, the Plan requested medical records to review the claim and these were not provided. 
Therefore, we decided that the Plan does not have to pay for the hepatitis C antibody test (86803) provided on 
July 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service June 7, 2022. 
 You asked the Plan to pay for procedure code 11721. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553,K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553,K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses. 
 
You asked the Plan to pre-approve eyeglasses. You say that you need new eyeglasses due to retinal detachment 
surgery on October 8, 2022. You say the retinal detachment surgery was an emergency so that you would not 
lose your vision, and since there is new eyeglass coverage for cataract surgery you are requesting the same 
coverage for the more serious retinal detachment surgery. The Plan denied your request. The Plan says the 
routine vision benefit is administered on a rolling calendar year since the last date of service. During the course 
of the Plan's review, it was confirmed that you last utilized this allowance on June 20, 2022. Therefore, you are 
not eligible to utilize this allowance again until June 20, 2023. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every year. 
 
We looked at the file and the Plan's rules. The file shows that you last utilized the eyewear benefit on  
June 20, 2022. Therefore, you are not eligible to utilize the eyewear benefit again until June 20, 2023. 
Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pre-approve eyeglasses.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria 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 that there is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. 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 she would meet 
criteria for admission to an acute inpatient rehabilitation facility. 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 acute IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70450 billed for date of service December 20, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says that the payment for code 70450 is included in the payment for code 
70496. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided any claim or evidence to show that the 
conflicting code, 70496, was also billed for this enrollee on this date by either the same provider or a provider 
within the same group of the same specialty. Since we cannot verify that a conflicting service/code was billed, 
the Plan's denial is not substantiated. Therefore, we decided that the Plan has to pay for procedure code 70450 
billed for date of service December 20, 2021.  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, the enrollee can safely get the services they need in other settings. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.