Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitation care. The 
documents do not support the medical necessity for admission to an IRF. While the enrollee may benefit from 
physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely addressed at a 
low intensity alternate setting such as in a skilled nursing facility (SNF).  
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections (J7318). 
 
You asked the Plan to pre-approve Durolane injections. You say that the injection is medically necessary. The 
Plan denied your request. The Plan says the criteria have not been met.  
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary 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 Durolane injections. Our reviewer says 
that the requested injection is not medically necessary. Our physician reviewer found the provided 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures prior to injection. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested injection in this clinical setting. The reviewer found there is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the reviewer found that the requested Durolane injection, 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 Durolane injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Durolane injections (J7318).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71046) provided on January 17, 2022. 
 
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your 
request. The Plan says this 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 71046 
is a column II code to column I code 71048, which was previously billed and paid. 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 an x-ray (71046) provided on 
January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (CPT code 64555 X 2) and ultrasonic guidance for needle 
placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation (CPT 
code 76942 X 2) to be provided by an out-of-network provider, Lake Hospital. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's records received do not indicate that they have an emergent or urgent 
medical condition or are in need of specialized service. The Plan states there are in-network provider(s) within 
a reasonable distance from the enrollee's location that can provide this service when medically necessary. The 
Plan states the enrollee can find a list of in-network providers in the enrollee's Provider Directory. 
 
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT 
code 64555 X 2) and ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization 
device), imaging supervision and interpretation (CPT code 76942 X 2) to be provided by an out-of-network 
provider, Lake Hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON ophthalmology services. You say that you need the requested 
OON provider to treat your Glaucoma. The Plan denied your request. The Plan says the services needed can be 
supplied by a network provider. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. Medicare rules 
also say that for Medicare to consider coverage and payment for any item or service, the information submitted 
by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and 
confirm that Medicare coverage criteria have been met. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found that the Plan made reasonable 
attempts to obtain medical records. However, there were no medical records supplied showing that there was a 
medical need to see an OON provider rather than a network provider. We found no exception that would 
require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-
approve ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) any joint of 
lower extremity (73721). 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee is having severe knee problems and an 
ultrasound has already shown that an MRI is needed as it was abnormal. The Plan denied your request. The 
Plan says the records do not support that the enrollee meets the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the record indicates that the enrollee has knee pain of nearly a year duration. The 
record does not indicate red flag physical examination findings and does not indicate that any treatment has 
been attempted. An ultrasound from July 2021 was reported to demonstrate muscle strain. The record does not 
indicate the occurrence of acute injury. The requested service is not medically necessary and reasonable for the 
diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria 
are not satisfied. The requested service cannot be recommended. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the magnetic resonance imaging (MRI) any joint of lower extremity (73721).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA disc procedure (percutaneous injection of 
allogenic cellular and/or tissue-based product). 
 
You asked the Plan to pre-approve the VIA procedure. You say that this would be a beneficial treatment for the 
enrollee's condition. The Plan denied your request. The Plan says there is not sufficient evidence to support 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 the VIA procedure. Our reviewer says 
that the requested items/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. Trial and failure of other supported treatment modalities have not all been exhausted. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
VIA disc procedure at L4/5 (percutaneous injection of allogenic cellular and/or tissue-based product, 
intervertebral disc), 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 the VIA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the VIA disc procedure (percutaneous injection of allogenic cellular and/or tissue-
based product).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered arm assist device (E1399, K0108). 
 
You asked the Plan to pre-approve the powered arm assist device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says this device is considered investigational at this time and 
is not covered. 
 
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 powered arm assist device. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device has not been shown to be superior to other standard treatments 
for the medical condition. The studies do not indicate the Kinova 0110 improves an individuals function or 
general health. 
 
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 powered arm assist device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a powered arm assist device (E1399, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated ankle foot orthosis (AFO) with 
static or adjustable stop coded as L1920 and a removable orthotic insert coded as L3031. 
 
You asked the Plan to pre-approve the custom AFO and orthotic insert. You say that this is a medically 
necessary treatment. The Plan denied your request. The Plan says criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that the requested type of AFO is reasonable and 
necessary for enrollees with deformity or weakness of the foot/ankle.  
 
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 custom AFO and orthotic insert. 
Our reviewer says that the requested AFO and insert are not medically necessary. Our physician reviewer 
found the enrollee is a 72-year-old woman with Peroneal tendinitis of the left leg, and Other enthesopathy of 
the left foot and ankle. The enrollee has previously tried a brace with little relief. Physical exam demonstrated 
no gross ankle deformity and no evidence of weakness. As such, the criteria for the AFO are not met. There is 
also no medical necessity noted for the insert. 
 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 custom AFO and orthotic insert have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a custom fabricated ankle foot orthosis (AFO) with static or 
adjustable stop coded as L1920 and a removable orthotic insert coded as L3031.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 15, 2021. 
 
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 provider did not bill as required by Medicare coding regulations. 
 
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 codes 87798 and 87481 are column II codes to column I code 87801. 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 
imaging services provided to the enrollee on July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the Intracept 
procedure is considered 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 77-year-old male being treated for spondylosis without 
myelopathy or radiculopathy, lumbar region; spondylosis without myelopathy or radiculopathy, lumbosacral 
region; other intervertebral disc degeneration, lumbar region; and low back pain. He presented with localized 
low back pain in the midline. He denies radiation, numbness, tingling, weakness, or incontinence. He notes the 
pain increases specifically when trail running and sleeping. Strength, sensation, and deep tendon reflexes are 
intact. There is decreased range of motion. There is some pain with bilateral segmental mobilization at L3-S1, 
worse with extension and rotation bilaterally.  
However, in this case, there were/are multiple plausible pathologic sources of significant pain generation. The 
magnetic resonance imaging (MRI) scan did note degenerative endplate changes are present throughout the 
lumbar region, most pronounced at the L1-2 and L4-5 levels; (however, was not specific in regards to those 
degenerative changes.) The non-radiating midline back pain, the noted pain-aggravating and pain-relieving 
factors, along with the diminished and painful spinal motion (in all directions) and intact neurologic exam 
were/are all non-specific to any pathologic entities. Overall, documentation was/is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
nerve ablation at L4, L5, and S1, 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says medical necessity rules for IRF care have 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 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 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 70450 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 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 the computed tomography (CT) scan of the head/brain rendered 
on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (CPT code 64624). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this type of procedure is considered 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve ablation is experimental for knee pain. More research is needed to show safety 
and efficacy. 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 service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed (CPT code 64624).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services (71045) provided to the enrollee on November 
22, 2021. 
 
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 there was active hospice enrollment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for x-ray services (71045) provided to the enrollee on November 
22, 2021.