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

 
We decided that the Plan does not have to pre-approve non-thermal radiofrequency ablation (RFA) to the 
thoracic facet joints (64633-50 and 64634-50). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not covered by Medicare or the Health Plan. 
 
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 services have not been met. The following requirement has not 
been met: there is neck or back pain that does not travel to other areas of the body. Based on Medicare LCD, this request because the following are needed: The treatment method used must be thermal (at least 80-degree 
Celsius heat) and non-pulsed (the heat is applied constantly for at least 60-90 seconds). Therefore, we decided 
that the Plan does not have to pre-approve non-thermal radiofrequency ablation (RFA) to the thoracic facet 
joints (64633-50 and 64634-50).
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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says at the time of the request, the enrollees status is stable 
and improving. The enrollee is receiving medically necessary acute and/or critical care. The member does not 
have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for 
which LTACH may offer a therapeutic advantage. 
 
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 the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that without SNF care it is putting the enrollee at risk for 
re-hospitalization. It would be doing the enrollee a significant disservice to his person and his safety as to not 
allow him to continue his therapy. The Plan denied your request. The Plan says the request is not medically 
necessary, the services the enrollee require can safely be received at a different setting, for example, home with 
home health.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the enrollee's records show that the enrollee's device will only be used 
in average volume-assured pressure support (AVAPS) mode, which is available on bilevel positive airway 
pressure (BiPAP) devices. 
 
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 the provided records document that the home ventilator is being requested for use in targeted 
tidal volume - volume assured pressure support (TTV-VAPS) mode with auto-titration (AE) which could be 
provided by a BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate.  
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 (E0466).
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 the enrollees third back surgery in a span of 4 
years. This time the bones didn't fuse like they were suppose too. The enrollee needs round the clock medical 
care that the enrollees caregiver/wife can't provide if the enrollee doesn't gain most of his independence back. 
He needs close medical monitoring due to his severe diabetic needs. The enrollee needs to have extensive PT to 
build their strength and independence back enough so he can return home. He is not at the base line needed to 
return safely to his home. The enrollee is a fall risk 
and requires assistance to use the bathroom, stand, and walk. The Plan denied your request. The Plan says the 
request is not medically necessary, the services the enrollee needs can be provided safely in other settings, for 
example, skilled nursing facility. 
 
 
 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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.
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 you are a fall risk and needs to stay with a physical 
therapist. The Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs 
can be met at a lower level of care such as a skilled nursing facility. 
 
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 you have osteoarthritis of the foot and ankle and is living at home with weakness and functional decline. Your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation 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 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 pay for procedure code 70450 billed for date of service October 21, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. 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 October 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 98928 provided on September 23, 2022. 
 
You asked the Plan to pay for code 98928. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the code billed is not supported. 
 
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 98928 is osteopathic manipulative treatment (OMT); 7-8 
body regions involved. 
 
We find that CPT code 98928 is not supported in the medical record. Specifically, the documentation submitted 
to the Plan did not include medical records. Without medical records, this code cannot be verified. Based on 
this information, we decided that Medicare rules for coverage of code 98928 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 98928 provided on September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the enrollee's records show that the enrollee's device will only be used 
in average volume-assured pressure support (AVAPS) mode, which is available on bilevel positive airway 
pressure (BiPAP) devices. 
 
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 the provided records document that the home ventilator is being requested for use in intelligent 
volume assured pressure support (IVAPS) mode with auto-titration (AE) which could be provided by a BiPAP 
device with average volume assured pressure support (AVAPS) and a back-up rate.  
 
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 (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code 76641. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large-volume, long-term, peer-reviewed outcome studies to support the use of the requested 
device for the enrollees medical 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Umano Ook Snow Bed (E1399). 
 
You asked the Plan to pre-approve Umano Ook Snow Bed. You say that the requested bed would ensure safe 
transfers as the enrollee does not have 24-hour care. You say that the electric height is crucial for safety when 
transferring. You say that the side rails will allow the enrollee to reposition as needed. You also say that this 
will allow the enrollee to maintain their independence and improve their quality of life. The Plan denied your 
request. The Plan says the documentation does not support why this specific bed is needed rather than an 
alternate hospital bed with approved Medicare codes. 
 
The Plan follows Medicare rules. Medicare rules say that a physician's prescription and such additional 
documentation as the Medicare Administrative Contractor (MAC) medical staff may consider necessary, 
including medical records and physicians' reports, must establish the medical necessity for a hospital bed. 
 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 Umano Ook Snow Bed. Our reviewer 
says that the requested Umano Ook Snow Bed is not medically necessary. Our physician reviewer found there 
is a lack of clinical documentation indicating why the enrollee requires the specific Umano Ook Snow Bed. 
The reviewer found that the appeal letter indicates that it would be used to manage the enrollees pulmonary 
function in addition to assist with pressure relief, re-positioning and transfers. The reviewer also found that 
there is no clinical history of pulmonary or cardiac issues that would necessitate this level of electric hospital 
bed. Therefore, the requested electric hospital bed, Umano Ook Snow Bed, is not 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 Umano Ook Snow Bed have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Umano Ook Snow Bed (E1399).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care aide services. 
 
You asked the Plan to pre-approve the personal care aide services. You say that this service is medically 
necessary. The Plan denied your request. The Plan says these services are custodial in nature and non-covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care aide services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal care aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or 
equal (L5981), and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5986). 
 
You asked the Plan to pre-approve a prosthesis and an advanced foot. You say that the enrollee would benefit 
from a more dynamic foot and ankle. You say that their current prosthetic foot is ill-fitting which limits their 
activity level. The Plan denied your request. The Plan says the records we have do not show why the requested 
prosthesis with an advanced foot is needed. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for a prosthesis and its components are 
based on the beneficiarys K-level modifier. 
 
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 prosthesis with an advanced foot. Our 
reviewer says that the requested prosthesis and an advanced foot are not medically necessary. Our physician 
reviewer found the provided documentation indicates the enrollee currently has definitive prosthesis with a total surface bearing socket and lock and pin suspension system. The reviewer found that there is insufficient 
clinical documentation regarding the enrollee's current level of mobility and function and why the enrollee 
requires the requested K3 prosthetic components. The prosthetic documentation indicates that the enrollee has 
the potential to be a K3 level ambulator, but the clinical documentation does not provide the enrollees mobility 
level and it is noted that they are requiring a manual wheelchair for mobility in their home. Additionally, there 
is insufficient documentation regarding the enrollees motor strength and range of motion in the lower 
extremities. This information is needed to determine if the requested prosthesis is appropriate and necessary. 
Therefore, the requested flex-walk system or equal (L5981), and addition to lower limb prosthesis, multiaxial 
ankle with swing phase active dorsiflexion feature (L5986) are not 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 a prosthesis with an advanced foot have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or equal 
(L5981), and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature 
(L5986).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a BaroStim Neo system (0266T, 
C1825). 
 
You asked the Plan to pre-approve a BaroStim Neo system. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/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 a BaroStim Neo system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. 
 
 
  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 BaroStim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a BaroStim Neo system (0266T, C1825).