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

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography (93460-LT). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that you want to appeal this denial. The 
Plan denied your request. The Plan says the requested procedure 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 cardiac catheterization. Our reviewer 
says that the requested cardiac catheterization is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records indicate that cardiac catheterization in 2020 showed 
insignificant coronary disease. The reviewer found that single-photon emission computed tomography 
(SPECT) imaging from December 2022 showed normal cardiac perfusion. The reviewer found that guidelines do not support a need for invasive cardiac catheterization in this setting. Therefore, the reviewer found that 
cardiac catheterization 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve catheter placement in coronary artery(s) for coronary angiography (93460-LT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator, electronic shock unit (E0745) 
provided on November 17, 2022. 
 
You asked the Plan to pay for a neuromuscular stimulator. You say that the enrollee is diagnosed with chronic 
pain and compromised mobility without the option for surgical correction. Medical records and requested 
documentation have been submitted for review. The Plan denied your request. The Plan says NMES is not 
covered for the documented diagnoses. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The information provided does not include any documentation of 
diffuse muscle atrophy where never supply to the muscle is intact, including brain, spinal cord, and peripheral 
nerves, or other non-neurological reasons for diffuse atrophy. Based on this information, we decided that 
Medicare rules for coverage of a neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pay for a neuromuscular stimulator, electronic shock unit (E0745) provided on November 
17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
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 goal is to get the enrollee back into IRF to 
complete goals. The Plan denied your request. The Plan says the records received do not indicate the enrollee 
needs nor can tolerate an intensive therapy program with multiple visits from a rehab doctor per week. The 
enrollee can safely receive the needed services other settings, for example: a skilled nursing facility, home with 
home health and home physical therapy. 
 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 the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for septic shock and endocarditis. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that this patient 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim NEO device (C1825 and 0266T). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the Barostim Neo device is considered unproven and 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollee's 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Barostim NEO device (C1825 and 0266T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on November 29, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are not covered by Medicare when the place of service is an ambulatory 
surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, you billed with place of service 24, which is an 
ambulatory surgical center. Medicare rules say that this equipment is for use inside the home. Medicare does 
not consider an ambulatory surgical center a home. Therefore, we decided that the Plan does not have to pay 
for a segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic compression device 
(E0675) provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot care services provided on December 5, 2022. 
 
You asked the Plan to pay for the foot care services. You say that you had a painful protrusion on your right 
foot about two inches below your little toe. You say that in the past you had callouses and corns removed and 
whatever the doctor removed on December 5, 2022, is back and fully regrown and you are having pain again. 
The Plan denied your request. The Plan says routine foot care is statutorily excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
foot care services have not been met. Therefore, we decided that the Plan does not have to pay for foot care 
services provided on December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 82607, 82670, 84270, 
84403, 84481, 86376, 80053 and 85027. We decided that the Plan does not have to pay for the services 
described by procedure code(s) 82306, 83036, 84436, and 84443.  
 
You asked the Plan to pay for laboratory services provided on August 30, 2022. You say that these services 
were medically necessary. The Plan says that codes 82306, 83036, 84436, and 84443 are denied because they 
are not a Medicare benefit for the diagnosis listed on the claim and were performed for screening purposes. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 82607, 82670, 84270, 
84403, 84481, 86376, 80053 and 85027.  
 
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) 82607, 82670, 84270, 84403, 
84481, 86376, 80053 and 85027.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
82306, 83036, 84436, and 84443. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these 
tests solely for screening purposes. Based on this information, we decided that Medicare rules for coverage of 
the services described by procedure code(s) 82306, 83036, 84436, and 84443 have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 82306, 83036, 
84436, and 84443. 
 
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 the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this would provide significant clinical and quality of 
life benefits for the enrollee. The Plan denied your request. The Plan says there is a lack of evidence to support 
that interspinous spacer devices are as safe and effective as the gold standard of decompression. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a prosthodontist. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says these services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
  
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by a prosthodontist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says CardioMEMS is not considered 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289 and C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Emerg Auto-Emersion therapy mattress. 
 
You asked the Plan to pre-approve the requested therapy mattress. You say that this mattress will provide the 
best treatment for pressure wounds. The Plan denied your request. The Plan says this mattress is not considered 
necessary as other support surfaces would meet the enrollee's needs. 
 
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 requested therapy mattress. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested mattress is being requested for the prevention of pressure injuries to the 
skin. The requested device has not been shown to be superior to other standard treatments for the medical 
condition. The requested mattress 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 requested therapy mattress have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Emerg Auto-Emersion therapy mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99306) rendered 
on September 30, 2022. 
 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99306 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented for initial 
nursing wound care appointment with a frontal scalp thick, overgrown lesion which appeared to be actinic 
keratosis and other AKs scattered on face/forehead. It was reported that she was recently in the hospital for 
acute kidney injury. Physical examination findings described only the head lesion. The provided records did 
not show that this note described a comprehensive history or physical for this patient and did not show 
evidence of medical decision making of high complexity. 
 
We looked at this coder'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 pay for initial nursing facility care (procedure code 99306) rendered on September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-country dialysis services. 
 
You asked the Plan to pre-approve out-of-country dialysis services. You say that the services are necessary 
while you are traveling. The Plan denied your request. The Plan says the requested services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for specific services, and certain services rendered on board a ship. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of out-of-country dialysis services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve out-of-country dialysis services.