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

 
We decided that the Plan does not have to pre-approve a knee orthosis (ko), double upright, thigh and calf, with 
adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or 
without varus/valgus adjustment, prefabricated, off-the-shelf (L1852). 
 
You asked the Plan to pre-approve a knee orthosis. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the request is not medically necessary 
because records show the enrollee does not have knee instability, or a recent knee injury or surgery. 
 
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 knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was evaluated for knee pain on January 18, 2023. The enrollee had stiffness of the 
knee without buckling or giving out. The enrollee also has a history of lumbar and thoracic spine pain with 
radiculopathy. Physical examination did not include an assessment of the knee. The enrollee was prescribed a 
knee brace to help with instability and notes that walking, standing, and stairs aggravates pain. The enrollee 
was evaluated for similar complaints in October 2022, and November 2022, and the examination was negative 
for instability, described as, stability testing of the knee is normal. There is no evidence of a knee flexion 
contracture, recent injury or surgery to the knee, or knee instability on exam. The enrollee is ambulatory. The 
criteria for the L1852 have not been met per LCD L33318. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension 
joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, 
prefabricated, off-the-shelf (L1852).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital inpatient or observation care (99233) provided 
on May 26, 2022. 
 
You asked the Plan to pay for the service. You say that the provider is in-network with the Plan. The Plan 
denied your request. The Plan says that this provider is not covered under open access unless preauthorized. 
 
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. According to the Plan's website, this provider is showing as an in-network 
provider with this specific Plan. Therefore, we decided that the Plan has to pay for the subsequent hospital 
inpatient or observation care (99233) provided on May 26, 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 IRF services requested are medically necessary. The 
Plan denied your request. The Plan says IRF services requested do not meet the requirements for approval. 
 
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 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 or an intensive rehabilitation therapy program. While the 
medical record supports a need for skilled therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. The member 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves (64640). 
 
You asked the Plan to pre-approve radiofrequency ablation of the genicular nerves. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
services 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 radiofrequency ablation of the genicular 
nerves. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the role of genicular nerve blocks and radiofrequency ablation is 
being investigated and is the subject of ongoing clinical trials. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the genicular nerves have not been met. Therefore, 
we decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves (64640).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided on August 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
without the appropriate modifier. 
 The Plan must follow Medicare rules. Medicare rules say that services furnished by teaching physicians 
involving a resident in the care of their patients must be identified as such on the claim, using either the GC or 
GE modifier as appropriate.  
 
We looked at the file and Medicare rules. The records show that the services in this case were provided by a 
resident. As such, the services must be billed with either the GC or GE modifier. 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 the services (99232) provided on August 4, 2022.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF services requested do not meet the requirements for approval. 
 
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 members nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member continues to have a need for skilled therapy; however, the member does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. The member 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee lives at home alone with no assistance 
and is at high risk for falling. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met in other settings. 
 
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 does not have any active medical comorbidities The enrollees needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), 
with any type of side rails, with mattress (E0260). 
 
You asked the Plan to pre-approve semi-electric hospital bed. You say that you have bed bugs, and you sprayed 
your home. If you do not get a new bed, you might run into the same problem with the bed bugs. The Plan 
denied your request. The Plan says the documentation does not indicate that you are primarily bed confined and 
requires frequent and immediate need for a change in body position to qualify for a semi-electric hospital bed. 
 
 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. 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 semi-electric hospital bed. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation does not 
support that you require positioning of the body in ways not feasible in an ordinary bed; or that your condition 
requires special attachments that cannot be fixed and used on an ordinary bed. Your condition does not require 
frequent change in body position and/or an immediate need for a change in body position (i.e., no delay can be 
tolerated). The criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), with any type of 
side rails, with mattress (E0260).
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 1 unit of code 64635. We decided that the Plan does not have to pay for 
an additional unit of code 64635.  
 
You asked the Plan to pay for procedure code 64635 billed for date of service January 17, 2022.. You say that 
the claim processed as a whole and not based on the fee schedule. The Plan says that the claim is an exact 
duplicate. 
 
We decided that the Plan has to pay for 1 unit of code 64635.  
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file does not show that code 64635 was reimbursed by the Plan 
on March 1, 2022. A comparison of the two claims does not show that the claim lines are exact duplicates. 
Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, we 
decided that the Plan has to pay for 1 unit of code 64635 provided on January 17, 2022.  
 
We also decided that the Plan does not have to pay for an additional unit of code 64635. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64635 is 1. The MAI value for this code is 2. You billed 2 units of this 
code on the date of service at issue, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for an 
additional unit of code 64635. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs diligent care due to 
multiple wounds that require daily wound care and daily physician monitoring. You say that the enrollee also 
requires respiratory care and LTACH level of care should be reconsidered for approval. The Plan denied your 
request. The Plan says transfer to an LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is improving but is not yet stable for transfer due to anemia. The enrollee 
should only require short-term additional acute care hospital services that can safely be provided at the current 
facility until they are more stable for a lower level of care. Completion of treatment at the current facility is 
recommended. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289). 
 
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 clinical value and effectiveness of the CardioMEMs device has not been 
demonstrated in the peer-reviewed literature. There remains a dearth of randomized, blinded clinical studies 
examining the long-term clinical outcomes to establish the value of CardioMEMS in patient management. 
 
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 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 CardioMEMS device (33289).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says transfer to an LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services at the LTACH that are not available at the acute care 
hospital or a skilled nursing facility. You can receive further care at the current hospital or a lower level of care 
when deemed appropriate. 
  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary, and the enrollee can safely receive the services in 
other settings. 
 
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 is medically stable and no acute rehabilitation nursing needs were 
identified or documented. While the enrollee may benefit from physical and occupational therapy, their needs 
can be provided in a lower intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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 an IRF admission is necessary. The Plan denied your 
request. The Plan says the member's needs can be met at a lower level of care. 
 
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 members nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member continues to have a need for skilled therapy; however, the member does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. The member 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.