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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the Medicare criteria for IRF admission were not met 
and the enrollee can receive the services they need in a lower level of care like at a skilled nursing facility 
(SNF). 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. The enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The enrollee needs physical 
therapy and occupational therapy in an alternate setting. 
 
The documentation does not support necessity for admission to an IRF due to lack of medical complexity and 
nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's 
rehabilitation needs can be provided in a lower intensity and alternate setting such as in an 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the transcatheter insertion or replacement of permanent leadless 
pacemaker, right ventricular, including imaging guidance and device evaluation (33274) provided on January 
19, 2021. 
 
You asked the Plan to pay for the leadless pacemaker. You say that the service was medically necessary. The 
Plan denied your request. The Plan says that there is no evidence the enrollee was part of an FDA approved 
study. 
 
The Plan must follow Medicare rules. Medicare rules say that, in prospective longitudinal studies, leadless 
pacemakers that are used in accordance with the FDA approved label for devices that have either an associated 
ongoing FDA approved post-approval study or completed an FDA post-approval study. 
 
We looked at the file and Medicare rules. Medicare covers leadless pacemakers when associated with an 
ongoing FDA approved post-approval study or completed an FDA post-approval study. The record shows that 
there is a clinical trial number reported on the claim and therefore is being tracked by a study. The record also 
shows that the study at issue is one in which all Medicare patients are enrolled when the device is placed. 
Based on this information, we decided that Medicare rules for coverage of the leadless pacemaker have been 
met. Therefore, we decided that the Plan has to pay for the transcatheter insertion or replacement of permanent 
leadless pacemaker, right ventricular, including imaging guidance and device evaluation (33274) provided on 
January 19, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal facet joint RFA (CPT code(s): 64635 and 
64636). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has completed both diagnostic MBBs 
at levels L4-5, L5S-1 and the enrollee reported over 80% relief. The Plan denied your request. The Plan says 
your request is not medically necessary because the enrollee's records show they do not have two diagnostic 
MBB yielding 80% or better improvement in your pain. 
 
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 services. Our physician reviewer 
found the NCD requires that both sets of diagnostic MBBs achieve 80% pain relief. This was achieved and 
therefore, the request is deemed 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 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal facet 
joint RFA (CPT code(s): 64635 and 64636).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 5, 2021, 
through November 23, 2021. 
 
You asked the Plan to pay for the home health services. You say that it is felt that the claim should be paid due 
to medical necessity. The Plan denied your request. The Plan says this was not billed with a 30-day period of 
care as required for Medicare home health services. 
 
The Plan must follow Medicare rules. Medicare rules say that the unit of payment for Medicare home health 
services is a 30-day period of care, though periods may be shorter. 
 
We looked at the file and Medicare rules. In this case, the period of care reported on the claim is greater than 
30 days. While periods of care may be shorter than 30 days, they may not be longer. Two periods of care would 
be billed in this situation. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from October 5, 2021, through November 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a precise tumor panel (81479). 
 
You asked the Plan to pre-approve a precise tumor panel. The Plan denied your request. The Plan says this 
request is not a covered benefit because the requested test does not have FDA approval or clearance as a 
companion in vitro diagnostic test for prostate cancer. 
 
 
 The Plan follows Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, when performed in a CLIA-certified laboratory, when ordered by a treating 
physician, and when all of the requirements listed in the Medicare rules section of this letter 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 a precise tumor panel. Our reviewer 
says that the enrollee does not meet the criteria for coverage for a precise tumor panel. Our physician reviewer 
found the records do not show that the enrollee has either recurrent, relapsed, refractory, metastatic, or 
advanced stage III or IV cancer; and has not been previously tested with the same test using NGS for the same 
cancer genetic content, and decided to seek further cancer treatment. Our reviewer also found that the requested 
test does not have FDA approval or clearance as a companion in vitro diagnostic test for prostate cancer. 
 
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 precise tumor panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a precise tumor panel (81479).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 6, 2021 billed with 
codes 81506, 81235, 81210, and 81275. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 6, 2021 billed with codes 81506, 81235, 81210, and 81275.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyPro powered arm brace. You say that the MyoPro is a custom 
fabricated orthosis designed to provide functional restoration of strength and range of motion to a 
neurologically impaired upper extremity. The device is medically necessary for the enrollee. The Plan denied 
your request. The Plan says the requested device is experimental and investigational procedures are not covered 
by Medicare. 
 
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 MyPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for the enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. The requested device is not reasonable and necessary for the diagnosis or treatment of an 
illness or injury or to improve the functioning of a malformed body enrollee. 
 
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 MyPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyPro powered arm brace (L8702).
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 the enrollee would like to reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says SNF is not medically 
necessary. The enrollee currently can get the help you need in a long-term care facility and the staff can help 
the enrollee move around. They can help the enrollee get out of bed, dress, and bathe; it is safe for the enrollee 
there. 
 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 documented skilled nursing needs. The enrollees care 
needs are custodial and can, as a practical matter, be provided 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 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 group 2 power wheelchair to include power tilt/recline 
and power elevating leg rests and upgraded electronics K0842 E1007, E2620, E0956, E1028, E2313, E2311, 
E0955, E2377, E1010, K0040, E2363, E0951, and E2622. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the provision of this wheelchair for this 
enrollee is consistent for patients with the enrollee's medical condition and is in the standards of good medical 
practice. The Plan denied your request. The Plan says the group 2 power wheelchair to include power 
tilt/recline and power elevating leg rests exceeds members needs for mobility and positioning. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. 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 enrollee has multiple medical problems causing functional deficits. 
Criteria for a power wheelchair are met. The documentation does not indicate that the member has any pressure 
injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or recline. The 
requested electrical accessories are not medically necessary as the enrollee does have use of the upper 
extremity and could operate and control the power options using the switches that are included in the basic 
wheelchair. The specifically requested group 2 power wheelchair with multiple power options 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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve group 2 power wheelchair to include power tilt/recline and power elevating leg 
rests and upgraded electronics K0842 E1007, E2620, E0956, E1028, E2313, E2311, E0955, E2377, E1010, 
K0040, E2363, E0951, and E2622.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan of the whole body (78816). 
 
You asked the Plan to pre-approve a PET CT scan of the whole body. 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 must follow Medicare rules. Medicare rules say that CMS continues to nationally non-cover FDG 
PET imaging for initial anti-tumor treatment strategy for the evaluation of regional lymph nodes in melanoma. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PET CT scan of the whole body have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) scan of the whole body (78816).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 16, 2021 billed 
with codes 81162, 81191, 81206, 81292, 81295, 81298, 81301, 81317, 81321, and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 16, 2021 billed with codes 81162, 81191, 81206, 81292, 81295, 81298, 81301, 81317, 81321, and 
81401.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medically necessary. The 
Plan denied your request. The Plan says the requested additional therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist to provide treatment safely and 
effectively. The enrollee has been educated in a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve four physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on July 22, 2022. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on July 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2022 billed with 
codes 81206, 81210, 81235, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 2, 2022 billed with codes 81206, 81210, 81235, and 81272.
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 these services are medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested IRF care is not medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a pelvic ramus fracture and sacral insufficiency fracture. Currently, they are at moderate assistance for transfers and ambulation. In this case, the enrollee does not require intensive 
rehabilitation services to recover from a pelvic fracture. Rehabilitation consists of walking as tolerated. The 
record shoes that they do not require frequent physical medicine and rehabilitation oversight. 
 
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.