Persius/hicric huggingface dataset:
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29891 and 27695 billed for date of service 
June 22, 2022. 
 
You asked the Plan to pay for procedure codes 29891 and 27695. 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 CPT codes 29891 and 27695 is 1. The MAI value for this code is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 29891 and 27695 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 29891 and 27695 billed for date of service June 22, 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's current medical condition requires 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 rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The member 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 member meets the criteria for admission to an acute inpatient rehabilitation facility. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product (VIA disc intradiscal therapy) (0627T). 
 
You asked the Plan to pre-approve VIA disc intradiscal therapy. You say that this treatment is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure is experimental 
and investigational. 
 
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 VIA disc intradiscal therapy. Our 
reviewer says that the requested VIA disc intradiscal therapy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is an experimental and investigational procedure. 
Therefore, the reviewer found that the requested VIA disc intradiscal therapy is not medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA disc intradiscal therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product 
(VIA disc intradiscal therapy) (0627T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery 
only, (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that the provided records support the 
necessity of the service. The Plan denied your request. The Plan says the Plan does not cover the use of bone 
marrow aspirate for this 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 bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee was being treated for lumbar radiculopathy and lumbar stenosis and 
presented with low back pain with symptoms that have been worsening. There are symptoms in the right lower extremity and there is weakness. The exam reveals positive straight leg raise in the right-hand side. The 
enrollee has extreme limitation in his back dynamics, with mild giveaway weakness. Sensation is decreased in 
the right foot. Reflexes are hypoactive throughout. Straight leg raise is positive. However, there is no specific 
indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this 
enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
bone marrow aspiration, 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 bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery only, (20939).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 the Intracept procedure 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has low back pain with 
neurogenic claudication. There is no documentation of failed non-surgical management after the enrollee's 
minimally invasive lumbar decompression (MILD) procedure to further improve his pain. Furthermore, the 
records are insufficient to establish the criteria for coverage have been met. The procedure is 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 an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted laparoscopy procedure rendered on August 10, 
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 record does not support this service. 
 
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 43659 is "Unlisted laparoscopy procedure, stomach." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the record states that the 
procedure was performed on the gastroduodenal junction and omentum. There is a more specific code for an 
unlisted procedure in this anatomical location. 
 
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 an unlisted laparoscopy procedure rendered on August 10, 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 requires inpatient rehab to help get her 
back to being independent. Without rehab, the member is a fall risk. The Plan denied your request. The Plan 
says the member does not meet 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 that in this case, the complexity of the members nursing, medical and rehabilitation 
needs does not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The member continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the member would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status.  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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77065 and G0279 billed for date of service 
August 8, 2022. 
 
You asked the Plan to pay for procedure codes 77065 and G0279. You say that the claim was billed correctly 
and should be paid. 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 CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. In addition, code G0279 cannot be billed without an appropriate primary procedure 
code. Based on this information, we decided that Medicare rules for coverage of procedure codes 77065 and 
G0279 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 77065 
and G0279 billed for date of service August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) non-segmental 
pneumatic appliances (E0666) segmental pneumatic appliances (E0673) and Orthotic(s) management and 
training (97760) provided August 3, 2022, to August 24, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that please pay and 
reprocess the claim. The Plan denied your request. The Plan says a pneumatic compression device that provides 
intermittent limb compression for the purpose of prevention of venous thromboembolism (which should be 
billed as E0676) is a preventive service and is excluded from coverage under the Medicare DME benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) non-segmental pneumatic appliances (E0666) segmental 
pneumatic appliances (E0673) and Orthotic(s) management and training (97760) provided August 3, 2022, to 
August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a face lift, neck lift, and blepharoplasty (15829, 15828, 
15825, 15824, 15823, 15822, 15820, 15821). 
 
You asked the Plan to pre-approve the face lift, neck lift, and blepharoplasty. You say that this procedure 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 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 face lift, neck lift, and 
blepharoplasty. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records provided do not indicate functional 
impairment or that the requested procedures are to repair a malformed body member. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules. 
 
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 face lift, neck lift, and blepharoplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a face lift, neck lift, and blepharoplasty (15829, 15828, 
15825, 15824, 15823, 15822, 15820, 15821).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care provided on March 16, 2022. 
 
You asked the Plan to pay for subsequent observation care. The Plan denied your request. The Plan says we 
have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been 
met. 
 
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 subsequent observation care have been 
met. Therefore, we decided that the Plan does not have to pay for subsequent observation care provided on 
March 16, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Kimyrsa. 
 
You asked the Plan to pre-approve Kimyrsa. The Plan denied your request. The Plan says that this drug it not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Kimyrsa. Our reviewer says that 
Kimyrsa is medically reasonable and necessary in this case. Our physician reviewer found that the record 
indicates that the enrollee has a diagnosis of local infections of the skin and subcutaneous tissue of the labia. 
The record indicates that the bacterial culture demonstrated methicillin resistant Staphylococcus aureus. The 
Food and Drug Administration has stated that the requested drug 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 Kimyrsa have been met. Therefore, we decided that the Plan has to pre-approve 
Kimyrsa.  
 
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 pay for code A4253 billed for dates of service April 29, 2022, to July 
28, 2022. 
 
You asked the Plan to pay for code A4253. The Plan denied your request. The Plan says code A4253 is 
considered bundled and 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 procedure code.  
We find that code A4253 has a status indicator of P on the Physician Fee Schedule. This means that code 
A4253 is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
code A4253 have not been met. Therefore, we decided that the Plan does not have to pay for code A4253 billed 
for dates of service April 29, 2022, to July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4550 billed for date of service October 10, 2022. 
 
You asked the Plan to pay for code A4550. The Plan denied your request. The Plan says code A4550 is 
considered bundled and 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 procedure code. 
 
We find that code A4550 has a status indicator of B on the Physician Fee Schedule. This means that code 
A4550 is not separately payable. Based on this information, we decided that Medicare rules for coverage of code A4550 have not been met. Therefore, we decided that the Plan does not have to pay for code A4550 billed 
for date of service October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin protection seat cushion (E2604). 
 
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no history of a pressure ulcer or decreased sensation in the area of contact with 
the wheelchair, or the inability to shift weight in the wheelchair. 
 
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 cushion. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence of a pressure sore, history of a pressure sore, or decreased sensation in any of the contact areas. The requirements are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the cushion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skin protection seat cushion (E2604).