Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health service. 
 You asked the Plan to pre-approve the home health service. You say that the service is medically necessary. 
The Plan denied your request. The Plan says Medicare covers a maximum of 35 hours per week of combined 
home health aide and skilled home nursing. 
 
The Plan must follow Medicare rules. Medicare rules say that that eligibility for the home health benefit will be 
determined based on the certifying physician or allowed practitioners records. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health service have not been met. Specifically, the documentation does not indicate how 
many hours per week have been previously authorized. Neither Medicare nor the Plan cover home health 
services that exceed 35 hours per week. Please note, the medical necessity of the home health aide and skilled 
nursing services is not at issue. Therefore, we decided that the Plan does not have to pre-approve the home 
health service.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 7, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not ordered by the treating provider. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
 
 
 
 
 We looked at the file and Medicare rules. The records do not show that the lab services in question were 
ordered by the enrollee's treating physician. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on February 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676 and E0673) 
provided on August 12, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like reconsideration 
because this device is instrumental in reducing the risk of post-operative complications. The Plan denied your 
request. The Plan says a Pneumatic Compression Device that provides intermittent limb compression for use as 
a preventative service or function is excluded from coverage under the Medicare durable medical equipment 
benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also 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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676 and E0673) provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot feature and 
additional components for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for K3 prosthesis, including microprocessor knee, does not meet Medicare 
criteria as reasonable and 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the the documentation does not support that the member is a K3 level ambulator; therefore, the requested 
advanced components are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an advanced knee/foot feature and additional components for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 7, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on October 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation lacks reasonably 
detailed evidence or findings supportive of the spinal vertebral bodies as being the overwhelming primary 
generators of the enrollees chronic persistent pain. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous nerve ablation at L5, S1, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home mechanical ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator with settings that could be delivered 
by bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) for this 
enrollee with post-COVID-19 is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee has post COVID-19 lung disease in the setting of interstitial lung disease and 
requires lung transplantation. The record indicates that the requested service has been ordered to provide 
ventilatory support. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with AVAPS capability. The plan has indicated such a device is available.  The elements of the 
coverage criteria are not satisfied. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable home mechanical ventilator for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 12, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 12, 
2021.
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 IRF is required to be approved under the primary 
diagnosis 189.0 Lymphedema, not elsewhere classified. You say you cannot walk, cannot drive, and have open 
wounds that need to be addressed. The Plan denied your request. The Plan says authorization denied because 
IRF is not medically necessary, and your needs can be met at a lower level of care such as 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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 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 pay for Percutaneous laminotomy/laminectomy (interlaminar 
approach) for decompression of neural elements (0275T) provided August 5, 2021. 
 
You asked the Plan to pay for the percutaneous laminotomy/laminectomy procedure. You say that please use 
attached documents to resume review of the case already in progress. The Plan denied your request. The Plan 
says the provider did not bill as required by Medicare coding regulations. 
 
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 0275T is percutaneous laminotomy/laminectomy 
(interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, 
discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, 
CT), single or multiple levels, unilateral or bilateral; lumbar. 
 
We find that CPT code 0275T is not supported in the medical record. Specifically, the mandatory clinical trial 
number was not reported on the claim. Based on this information, we decided that Medicare rules for coverage 
of the percutaneous laminotomy/laminectomy procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for Percutaneous laminotomy/laminectomy (interlaminar approach) for 
decompression of neural elements (0275T) provided August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (CPT code 
E0277). 
 
You asked the Plan to pre-approve the powered pressure-reducing air mattress. You say that the enrollee has a 
brain injury, not able to move themselves, and is at high risk for developing pressure ulcers. The Plan denied 
your request. The Plan says the records do not show that the enrollee currently has pressure ulcers, and there is 
no documentation that the enrollee has had a recent myocutaneous flap or skin graft. 
 
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 powered pressure-reducing air 
mattress. Our physician reviewer found the enrollee has limited mobility due to their medical condition. The 
documentation does not support that the enrollee has multiple stage 2 pressure ulcers located on the trunk or 
pelvis and has failed to improve in the previous month with conservative treatment with a comprehensive ulcer 
treatment program or a myocutaneous flap or skin graft. The requested pressure reducing support surface 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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (CPT code E0277).
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 care is medically necessary, and if the enrollee 
is forced to go to a SNF, she will not get the therapy she needs and deserves to be able to regain her strength 
and independence. The Plan denied your request. The Plan says authorization denied because IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as 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 the enrollee's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. 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 has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 still has confusion and requires ongoing acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH facility. 
 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound exam of the head and neck (76536) provided 
on November 7, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that this claim was denied as a duplicate in error. The 
Plan denied your request. The Plan says this is a duplicate of a previous claim which was already paid. 
 
The Plan must follow Medicare rules. Medicare rules say that an exact duplicate for institutional claims is a 
claim or claim line that exactly matches another claim or claim line with respect to certain elements.  
 
We looked at the file and Medicare rules. The documentation in this case shows that the Plan has processed and 
paid another claim for the same date of service, same billed amount, same CPT code and modifier, performed 
by the same provider for the same enrollee. There is no documentation to support that two of this same ultrasound were performed on the date in question. Based on this information, we decided that Medicare rules 
for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultrasound exam of the head and neck (76536) provided on November 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
"functional household distance" with a rolling walker with contact guard assistance and is contact guard assist 
for transfers. Provided records do not document a significant decline in the enrollees functional status to 
necessitate daily inpatient skilled therapy services. The enrollee does not require the services on an inpatient 
basis, only in a skilled nursing facility setting. Records do not document that services in the home with home 
health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you need this denture to be 
approved because you cannot eat properly and digest your food without it. The Plan denied your request. The 
Plan says this service exceeds the maximum count allowed per period. 
 
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. 
 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular partial denture (D5212) is 
limited to one procedure every five plan years. The record shows that you received a mandibular partial denture 
(D5214) on December 22, 2020 and your mandibular denture benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation 
procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
those patients that do not receive adequate relief from traditional conservative methods and don't have 
instability to indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says this is 
procedure remains experimental at this time. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found this procedure is considered experimental for low back pain. More research is 
needed to support medical necessity. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation procedure.