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

 
We decided that the Plan does not have to pre-approve the use of Dayspring non-pneumatic compression 
devices (K1024, K1033). 
 
You asked the Plan to pre-approve non-pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve non-pneumatic compression devices. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the provided medical records do not document adequate trial and failure of 
conventional lymphedema management techniques including manual lymphatic drainage, compression 
garments and pneumatic compression treatment. Review of the current peer-reviewed medical literature 
indicates uncertain utility of the Dayspring non-pneumatic compression device compared with conventional 
therapies with unproven long-term health benefit. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-pneumatic compression devices have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the use of Dayspring non-pneumatic compression devices (K1024, 
K1033).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator (L8679), and 
percutaneous implantation of neurostimulator electrode array (64555). 
 
You asked the Plan to pre-approve a post-auricular neurostimulator. You say that this item is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested neurostimulator is 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 post-auricular neurostimulator. Our 
reviewer says that the requested post-auricular neurostimulator is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested item is considered experimental and 
investigational. Therefore, the reviewer found that the requested item 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 a post-auricular neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable neurostimulator (L8679), and percutaneous implantation 
of neurostimulator electrode array (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous passive motion exercise device (E0936), 
provided on May 17, 2022. 
 
You asked the Plan to pay for the continuous passive motion exercise device. You say that the item is 
medically necessary. The Plan denied your request. The Plan says this item is not covered for your diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous passive motion devices are devices 
covered for patients who have received a total knee replacement. To qualify for coverage, use of the device 
must commence within 2 days following surgery. In addition, coverage is limited to that portion of the 3-week 
period following surgery during which the device is used in the patients home. There is insufficient evidence 
to justify coverage of these devices for longer periods of time or for other applications. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous passive motion exercise device have not been met. Specifically, you who have not 
received a total knee replacement.  Therefore, we decided that the Plan does not have to pay for the continuous 
passive motion exercise device (E0936), provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial observation care provided on April 7, 2020. 
 
You asked the Plan to pay for the hospital care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that the service was not medically necessary. 
 
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 file does not contain documentation to support that this service 
was billed by another provider on the date of service in this case. Therefore, we decided that the Plan has to pay 
for the initial observation care provided on April 7, 2020.  
 
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: Favorable

 
We decided that the Plan has to pre-approve the revascularization (37230, 37227, 37226, 37221). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are necessary. The Plan 
denied your request. The Plan says that there is no evidence that the enrollee cannot perform the enrollee's 
activities of daily living, or have tried cilostazol, structured exercise or been offered a surgical alternative. 
 
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 surgical services. Our physician 
reviewer found the documentation meets coverage criteria. There is satisfactory documentation that the 
enrollee is having lifestyle limiting claudication and has computed tomography angiography (CTA) 
confirmation of right superficial femoral artery occlusion. Treatment of lifestyle limiting claudication is an 
approved indication for treatment by the Health Plan and the CTA confirms disease proximal to the tibial 
arteries. The reported ankle brachial index (ABIs) are consistent with the CTA results as well. 
 
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 surgical services have been met. Therefore, we decided that the Plan has to 
pre-approve the revascularization (37230, 37227, 37226, 37221).  
 
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 a Latera nasal implant (30468). 
 
You asked the Plan to pre-approve a Latera nasal implant. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Latera nasal implant. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has nasal valve collapse due to facial nerve paralysis. There is insufficient 
literature to support the use of the requested procedure for the enrollee's specific clinical condition. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. 
 
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 Latera nasal implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Latera nasal implant (30468).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve micro-invasive glaucoma surgery (MIGS). 
 
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 MIGS 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 records show that you have an age 
age-related nuclear cataract and pre-glaucoma. There is no documentation that you are being treated with 
glaucoma eye drops. The records do not support that the requested procedure is for the treatment of moderate 
open-angle glaucoma and a cataract while being treated with medication in conjunction with cataract surgery. 
The criteria for coverage are not met and the services are not 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 micro-invasive glaucoma surgery (MIGS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service December 
17, 2021. 
 
You asked the Plan to pay for procedure code 97010. The Plan denied your request. The Plan says procedure 
code 97010 is considered bundled and 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 procedure code. Medicare rules also say that the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Additionally, the requested infrared therapy is not medically 
necessary per NCD 270.6. Based on this information, we decided that Medicare rules for coverage of procedure 
code 97010 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
97010 billed for date of service December 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve duplex scan of extremity veins including responses to 
compression and other maneuvers; complete bilateral study (93970) to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network service. You say that the service is necessary. The Plan 
denied your request. The Plan says there is an in-network provider that can perform the services the enrollee 
needs. 
 
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 duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral 
study (93970) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 11, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that wound pathogen panels are 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee was seen on May 11, 2022 
with a left heel wound. The records document that the wound was cleansed, debrided, and a sterile culture was 
obtained by swab. There is no documentation of specific reasons for performing the panel testing at issue. The 
services were not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97010 and 97026 billed for date of service 
December 21, 2021.  
You asked the Plan to pay for procedure codes 97010 and 97026. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure code 97010 is considered bundled and 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 procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable.  Code 97026 is infrared therapy services. These services are 
specifically not covered. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 97010 and 97026 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 97010 and 97026 billed for date of service December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) supply allowance. 
 
You asked the Plan to pre-approve the supply allowance. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the supply allowance. Our reviewer 
says that the requested supply allowance is not medically reasonable and necessary. Our physician reviewer 
found that this enrollee does not use insulin, so she does not meet the coverage criteria. 
 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 supply allowance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) supply allowance.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal aortic aneurysm (AAA) screening (76706) 
provided on June 29, 2022. 
 You asked the Plan to pay for the AAA screening. You say that this test was medically necessary and was 
referred by the enrollees treating physician. The Plan denied your request. The Plan says the coverage criteria 
for this screening are not met. 
 
The Plan follows Medicare rules. The rules say that payment may be made for a one-time ultrasound screening 
for AAA for beneficiaries who meet certain criteria. 
 
We looked at the file and Medicare rules. There is insufficient information in the case file to show that the 
enrollee is in one of the qualifying risk categories. We cannot confirm that the criteria for coverage of this 
screening have been met in this case. Therefore, we decided that the Plan does not have to pay for an 
abdominal aortic aneurysm (AAA) screening (76706) provided on June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination tilt-and-recline power seating system 
(E1007) for a power wheelchair. 
 
You asked the Plan to pre-approve a power seating system. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the request is 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 power seating system. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you do not have skin breakdown, use a catheter or have spasticity. The criteria for a power 
tilt or tilt and recline system are not part of your 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 power seating system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a combination tilt-and-recline power seating system (E1007) for a power 
wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Medtronic Infuse Bone Morphogenetic Proteins (BMP)
allograft services.

You asked the Plan to pre-approve Medtronic Infuse BMP allograft services. You say that the records provided
support the need for the services which remain in dispute. The Plan denied your request. The Plan says the
clinical value and effectiveness of the Medtronic Infuse BMP Allograft in the setting of posterolateral lumbar
spine fusion surgery have not been demonstrated in the peer-reviewed literature.

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 Medtronic Infuse BMP allograft
services. Our reviewer says that Medtronic Infuse BMP allograft services are not considered medically
reasonable and necessary in this case. Our physician reviewer found BMP remains experimental in the
posterior lumbar spine. More research is needed to show safety and efficacy when used in the posterior lumbar
spine. Iliac crest autograft is the gold standard.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Medtronic Infuse BMP allograft services have not been met. Therefore, we
decided that the Plan does not have to pre-approve Medtronic Infuse Bone Morphogenetic Proteins (BMP)
allograft services.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87651, 87653, 87481, 
87500, 87640 and 87641. We decided that the Plan does not have to pay for the services described by 
procedure code(s) 87798 (10 additional units).  
 
You asked the Plan to pay for laboratory services provided on March 28, 2022. You say that these services 
were necessary and are supported as billed. The Plan says that the number of units of 87798 billed exceeds the 
maximum allowed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87651, 87653, 87481, 
87500, 87640 and 87641.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 87651, 87653, 87481, 87500, 
87640 and 87641.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 87798 
(10 additional units). 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 23 units of this 
code, exceeding the MUE by 10 units. You did not provide all the required evidence showing that the excess 
units were actually provided, were correctly coded, and were medically necessary. Based on this information, 
we decided that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 87798 (10 additional 
units). 
 
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.