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

 
We decided that the Plan does not have to pay for vascular procedures (37225, 36247, 37229, 75710, 37252, 
37253) provided on June 24, 2022. 
 
You asked the Plan to pay for the vascular procedures. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the codes billed. 
 
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 code 37225, 36247, 37229, 75710, 37252, 37253 is not supported in the medical record. 
Specifically, medical records provided do not include sufficient documentation to validate that a 
revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
atherectomy, including angioplasty within the same vessel was performed on the date of service. Records 
provided do not include sufficient documentation to validate that a selective catheter placement was performed. 
The medical records provided do not include sufficient documentation to validate that an Angiography, spinal, 
selective, radiological supervision and interpretation was performed. The medical records provided do not include sufficient documentation to validate that an Intravascular ultrasound was performed. Based on this 
information, we decided that Medicare rules for coverage of the vascular procedures have not been met. 
Therefore, we decided that the Plan does not have to pay for vascular procedures (37225, 36247, 37229, 75710, 
37252, 37253) provided on June 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 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 documentation shows that the enrollee has had clinical and functional status 
change thus would require skilled nursing and skilled therapy. Evaluating therapists (physical therapy, 
occupational therapy) both recommend intermittent skilled therapy in a home setting or outpatient and there is 
no clear recommendation for frequency of skilled nursing required thus from a practical standpoint the enrollee 
does not require daily skilled services on an inpatient basis in a skilled nursing facility. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on August 11, 2022. 
 
You asked the Plan to pay for definitive UDT for 22 or more drug classes. You say that this is a Medicare-
covered test that was determined to be medically necessary by the treating physician. The Plan denied your 
request. The Plan says ordering a multiclass panel of definitive (confirmation) urine drug tests that are not used 
in clinical management, exceeds the needs of the enrollee. 
 
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 pay for definitive UDT for 22 or more drug classes. Our reviewer says that the requested testing does not meet criteria for coverage. Our physician reviewer found 
that provided records do not document the results of a screening UDT that are presumptively positive or results 
of the screening UDT are negative, and this negative finding is inconsistent with the enrollee's medical history 
or that there was no presumptive test available, locally and/or commercially. Thus, the testing does not meet 
criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive UDT for 22 or more drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483) provided on August 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76815 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 76815. You say that this was performed as a separate service. 
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 76815 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76815 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76815 billed for date of service August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services. 
 
You asked the Plan to pre-approve revascularization services. You say that the requested services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that stenting of vessels is covered only when all of the 
conditions 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 revascularization services. Our 
reviewer says that the requested revascularization services are not medically necessary. Our physician reviewer found the provided documentation does not indicate peripheral pulses are present. The reviewer found that the 
enrollee has not trialed medical therapy of either peripheral vascular disease or varicose veins. Therefore, the 
reviewer found that the requested services are 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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee surgery (29874, 29876, 29877, 29880 and 
29881). 
 
You asked the Plan to pre-approve a knee surgery. You say that the services are medically necessary. 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 a knee surgery. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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. You are noted to have a complex tear 
of the medial meniscus, however, with degenerative changes as well. Additionally, detailed documentation is 
not evident regarding a trial and failure of recent, reasonable, and comprehensive less invasive conservative 
care measures. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. 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 a knee surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee surgery (29874, 29876, 29877, 29880 and 29881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the 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 you do not use insulin with at least 
three daily injections, and you do not require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
CGM and supplies
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the hospital bed and support surface 
mattress pad provided on May 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to provide reimbursement for the OON medical equipment. You say that the enrollee was 
not able to be seen by a doctor to get a prescription for this equipment as he was not able to find his 
identification. The Plan denied your request. The Plan says this was not ordered by an in-network treating 
physician. The medical necessity of these items is not supported. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to provide reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to provide reimbursement for these items/services. Therefore, we decided that the Plan does not have to provide reimbursement for the hospital bed 
and support surface mattress pad provided on May 24, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 18, 2022, to 
February 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 18, 2022, to 
February 16, 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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this has a lack of medical necessity. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item is considered experimental. 
 
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 MyoPro orthotic device. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this 
patient or that this device will increase participation in bimanual activities. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
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 RFA 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 chronic axial low back 
pain and had an epidural steroid injection (ESI) and sacroiliac (SI) joint injection. He underwent diagnostic 
facet injections and had greater than 80 percent pain relief. There is no documentation of a second set of 
diagnostic blocks. The criteria are not met until a second set is performed; therefore, RFA is not reasonable or 
medically necessary at this time. 
 
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 radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to a LTACH and may be adequately cared for with the current medical condition. The Plan denied your 
request. The Plan says there is no need to transfer to a LTACH at this time, the enrollee is receiving the care 
needed in the current hospital. 
 
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 are no services available at the LTACH the enrollee requires that are not 
available at the health care setting being currently offered by the health plan. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (S0164) provided on July 11, 2022. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 code S0164 is not supported in the medical record. Specifically, this code is not recognized 
by Medicare for outpatient claims. Based on this information, we decided that Medicare rules for coverage of 
the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections 
(S0164) provided on July 11, 2022.
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 ventilator is medically necessary for the 
enrollee due to a significant medical history to include diabetes, hypertension, hypothyroidism, COPD/Asthma 
on continuous home oxygen at 4 LPM, and GERD. The Plan denied your request. The Plan says the request for 
a home mechanical ventilator set in AVAPS 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 service is not medically necessary. Our physician reviewer found provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in 
the Local Coverage Determination (L33800): Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not 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 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapy to regain maximum functions and 
strengths so you may recover and care for yourself. The Plan denied your request. The Plan says the records do 
not show that you have complex rehabilitation needs that require frequent evaluation by a rehabilitation doctor 
or that you will be able to tolerate the intensity of IRF services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.