Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a high frequency chest wall oscillation device (HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that vest therapy is beneficial for you. You also say 
that it is a medically necessary part of your treatment plan. The Plan denied your request. The Plan says that the 
documentation provided does not indicate that you have a diagnosis of bronchiectasis. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that a 
HFCWOD is medically necessary. Our physician reviewer found the record indicates that you have chronic 
obstructive pulmonary disease. The reviewer found that additional records obtained include a computed 
tomography (CT) scan of the chest demonstrating the presence of bronchiectasis. The record indicates that you 
had previously failed standard therapies and required the requested service to clear secretion. Therefore, the 
reviewer found that a HFCWOD is medically reasonable and necessary in this case. 
 
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 HFCWOD have been met. Therefore, we decided that the Plan has to pre-
approve a high frequency chest wall oscillation device (HFCWOD).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve an ESI. You say that the ESI is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the requested ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain 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 an ESI. Our reviewer says that an ESI is 
medically necessary. Our physician reviewer found the provided documentation clearly demonstrates L5 and 
S1 radiculopathy. Therefore, the reviewer found that an epidural steroid injection (ESI) is 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 an ESI have been met. Therefore, we decided that the Plan has to pre-approve 
an epidural steroid injection (ESI) (62323).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 enrollee has progressed rapidly from moderate assistance to minimum assistance 
with low-level hospital rehabilitation services. The enrollee's performance and deconditioned post-acute status indicate the enrollee does not require 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pemetrexed (J9305) and dexamethasone sodium 
phosphate (J1100). 
 You asked the Plan to pre-approve the medication. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee is enrolled in a clinical trial NCT05014815. The Plan states the 
physician reviewer determined coverage of the requested drug would be deemed a 
routine cost covered by the Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the medication as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Pemetrexed (J9305) and dexamethasone sodium phosphate (J1100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88108 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 88108. The Plan denied your request. The Plan says payment for 
code 88108 is bundled into payment for code 88112.  
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 88108 
is a column II code to column I code 88112. 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 88108 billed for date of service August 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that the enrollee 
did not have a consistent minimum of 80% sustained relief of primary (index) pain with the previous medial 
branch blocks. The review has determined that the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve MPI. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is indicated under 
certain circumstances. 
 
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 MPI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has no cardiac signs or 
symptoms. There is no documentation that the electrocardiogram (ECG) shows an uninterpretable pattern or 
that the enrollee is unable to exercise. There is no evidence provided that would support the need for 
radionuclide stress testing at this time. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac stress testing in this enrollees clinical 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 MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging (MPI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on September 6, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this device was used outside the home and is not 
eligible for coverage. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0673, E0675) provided on September 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29846 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the procedure is 
inclusive to the main procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We find that CPT code 29846 was billed with open procedure code 25447. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 29846 billed for date of service September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion with an out-of-network (OON) 
provider. 
 You asked the Plan to pre-approve a second opinion with an OON provider. You say that the enrollee has 
metastatic large cell neuroendocrine carcinoma involving her liver. You say that you want to get a second 
opinion on treatment options. You say that the requested OON provider has experience with the type of cancer 
the enrollee has. The Plan denied your request. The Plan says the enrollee has no OON benefits and 
participating oncologist are available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 second opinion with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the Plan is offering adequate care to meet the enrollee's medical needs through referred to in-
network oncologists. There is nothing unique about the enrollee's condition that would make it medically 
necessary for her to see the requested OON provider. The plan has shown that they have in-network providers 
how meet the Standards of Care required for treatment of 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 a second opinion with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a second opinion with an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric bed. You say that the requested device is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not require frequent 
and immediate need for a change in body position to qualify for a semi-electric hospital bed. 
 
The Plan follows Medicare rules. Medicare rules say a semi-electric hospital bed is covered if the beneficiary 
meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an 
immediate need for a change in body position. 
 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 semi-electric bed. Our reviewer says 
that a semi-electric bed is not medically necessary. Our physician reviewer found the provided records do not 
document the need for frequent and immediate changes in body position. Therefore, the reviewer found that the 
requested semi-electric bed is not medically reasonable or 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 a semi-electric bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a semi-electric bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat caudal epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the enrollee's last caudal ESI was August 26, 
2021. The Plan denied your request. The Plan says the requested repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee had 50% pain relief for three months from the previously ESI. Therefore, the reviewer 
found that a repeat ESI 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat caudal epidural steroid injection (ESI) (62323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 64494 and 64495 billed for November 24, 2021. 
 
You asked the Plan to pay for codes 64494 and 64495. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 
64494 and 64495 are add-on codes and have not been billed with an appropriate primary procedure code. Code 64494 must be billed with primary code 64493. As code 64494 is not payable in this case, code 64495 is also 
not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for codes 64494 and 64495 billed for November 24, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for human papillomavirus (HPV) testing (87624) provided on August 25, 
2022. 
 
You asked the Plan to pay for HPV testing. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial rationale states that the service at issue is non-
covered under the geographically applicable Local Coverage Article. We determined that the Article in 
question does not indicate non-coverage for procedure code 87624. 
 
The Plan has not provided an alternative rationale for denial. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for human papillomavirus (HPV) testing (87624) provided on 
August 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary to maximize the enrollee's 
functional outcome. The Plan denied your request. The Plan says ongoing skilled care can be provided in an 
alternative setting. 
 
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 no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (CPT 99222), a neck/spine x-ray  
(CPT 72040), an x-ray of jaw (CPT 70100), diagnostic radiology procedures of the head and neck  
(CPT 70310), a swallowing function x-ray (CPT 74230) and an upper gastrointestinal tract x-ray (CPT 74240) 
provided on October 20, 2022. 
 
You asked the Plan to pay for initial hospital care (CPT 99222), a neck/spine x-ray (CPT 72040), an x-ray of 
jaw (CPT 70100), diagnostic radiology procedures of the head and neck (CPT 70310), a swallowing function 
x-ray (CPT 74230) and an upper gastrointestinal tract x-ray (CPT 74240). You say that the services were 
medically necessary. The Plan denied your request. The Plan says based on the clinical information submitted, 
the requested services are not in accordance with accepted standards of medical practice; and exceeds the 
medical needs of the member.  
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file shows that these services were performed at a nursing home 
(via mobile van/portable x-ray) which is an excluded place of service per the Medicare LCD coverage criteria. 
Therefore, we decided that the Plan does not have to pay for initial hospital care (CPT 99222), a neck/spine 
x-ray (CPT 72040), an x-ray of jaw (CPT 70100), diagnostic radiology procedures of the head and neck (CPT 
70310), a swallowing function x-ray (CPT 74230) and an upper gastrointestinal tract x-ray (CPT 74240) 
provided on October 20, 2022.