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

 
We decided that the Plan does not have to pre-approve a StimQ device for the enrollee's knee pain (CPT) 
code(s): 64555, 95972 and L8680). 
 You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the StimQ peripheral cutaneous nerve stimulator does not fit the Medicare definition of 
an implanted peripheral nerve stimulator. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided and review of the current peer-reviewed medical 
literature (Up to Date) there is inadequate information to clarify that the StimQ device at issue in this case 
meets all Medicare criteria for medically reasonable and necessary, safe and effective for the enrollee, per 
Social Security Act, Section 1862(a)1(A). Provided records and the current peer-reviewed medical literature 
(Up to Date) do not support the long-term safety and efficacy of devices such as the StimQ device for treating 
chronic pain syndrome with osteoarthritis of the knee and back. The requested device does not meet the 
definition of a dorsal column or depth brain stimulator addressed by the NCD: Electrical Nerve Stimulators 
(160.7). 
 
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 StimQ device for the enrollee's knee pain (CPT) code(s): 64555, 95972 and L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), lumbar or sacral; single 
level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet joint with image guidance 
(fluoroscopy or CT), lumbar or sacral (64494). 
 
You asked the Plan to pre-approve injections. You say that the enrollee is going to have another surgery in a 
month for her rotator cuff and she will not be able to lay on that shoulder. The injections will be necessary for 
her to be able to tolerate the surgery procedure and recover as well as not to endure chronic pain on a daily 
basis. The Plan denied your request. The Plan says the request is not medically necessary because the enrollee's 
records show she has untreated radiculopathy and also has a sacral fracture. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presented with low back and left hip pain following a recent fall and was diagnosed 
with a sacral fracture. She received conservative treatment but still has low back pain which radiates down to 
her hips. She has received pain medications, aquatic therapy, and epidural steroid injections for the same with 
no significant relief. Her last MRI lumbar spine done in May 2021 showed multilevel lumbar spondylosis 
without central canal stenosis with L5-S1 paracentral bulge resulting in displacement of the left S1 nerve root 
posteriorly. The enrollee has several other probable pain generators and therefore does not meet the LCD 
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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with 
image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or 
therapeutic agent, paravertebral facet joint with image guidance (fluoroscopy or CT), lumbar or sacral (64494).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent testing (87798) provided on July 21, 2022. 
 
You asked the Plan to pay for infectious agent testing. You say that this should be covered. The Plan denied 
your request. The Plan says there are not records to support this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of infectious agent testing have been met. 
No records documenting that these services were performed and were medically necessary have been submitted by you or the provider. Therefore, we decided that the Plan does not have to pay for infectious agent testing 
(87798) provided on July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 20, 2022, billed with 
codes 81210, 81120, 81121, 81206, 81235, 81245, 87270, 81272, 81275, 81276, 81310, 81311, 81315, 81194, 
and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 20, 2022, billed with codes 81210, 81120, 81121, 81206, 81235, 81245, 87270, 81272, 81275, 81276, 
81310, 81311, 81315, 81194, and 81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot inserts. You say that you would like reconsideration because the 
requested foot inserts are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is considered experimental and 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 the service. 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. More research is needed. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex 
superion device placement surgery (CPT code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen by different providers. The 
Plan denied your request. The Plan says the service was already billed for this date of service. 
 
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 99221 is initial hospital care, per day, for the evaluation 
and management of a patient. 
 We find that CPT code 99221 was billed twice by the same provider on the date of service at issue. Code 
99221 may be reported only once per day by the same physician. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99221 billed for date of service February 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 15, 2022, to 
April 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 15, 2022, to April 
13, 2022.
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. The Plan denied your request. The Plan says the enrollee's records 
do not show they need rehabilitation care 24 hours a day. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has been functioning at a 1 level with ambulation and required 
comprehensive geriatric assessment for assisted daily living activity skills. The enrollee has a new prosthesis 
and has lived and functioned with her amputation and multiple prostheses for 11 years.  There has been no change in functional capacity and does not require intensive rehabilitation or frequent 
physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided October 19, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you would like to 
appeal the decision to not pay for certain therapies instrumental in reducing the risk of post-operative 
complications. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
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 (E0675) and segmental pneumatic appliance (E0673) provided 
October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (CPT code E2377), harness for 
upgrade to expandable controller (E2313) and electronic connection between wheelchair controller and two or 
more power seating system motors, including all related electronics, indicator feature, mechanical function 
selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The electrical connection between the 
wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) 
cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. The 
enrollee is independent with self-feeding. The enrollee's upper limb strength and function are adequate for the 
member to be able to control the power options using their own switches which are included in the allowance 
of these power options. Therefore, we decided that the Plan does not have to pre-approve expandable controller 
(CPT code E2377), harness for upgrade to expandable controller (E2313) and electronic connection between 
wheelchair controller and two or more power seating system motors, including all related electronics, indicator 
feature, mechanical function selection switch, and fixed mounting hardware (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor system 
(K0554) and supply allowance used with a therapeutic CGM device (K0553). 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 CGM and supplies. You say that you are in need of 
the FreeStyle Libre due to not being able to get blood when checking your blood surgery. It is medically 
necessary, and you need it immediately. The Plan denied your request. The Plan says the enrollee does not 
meet all of the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the FreeStyle Libre 2 CGM and supplies have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous 
glucose monitor system (K0554) and supply allowance used with a therapeutic CGM device (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the paravertebral facet joint injections (CPT code(s): 
64493RT and 64494RT). 
 
You asked the Plan to pre-approve the injections. You say that the injections are necessary. The Plan denied 
your request. The Plan says the enrollee did not receive consistent relief from the first diagnostic facet joint 
procedure as they reported 30 percent relief to the right side of the back for two to three hours. 
 
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 injections. Our physician reviewer 
found the LCD criteria is 80% pain relief after diagnostic MBB. This was not achieved and therefore, the 
request is deemed not medically reasonable and 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the paravertebral facet joint injections (CPT code(s): 64493RT and 64494RT).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95909 and 95886 provided on February 8, 2022. 
 
You asked the Plan to pay for codes 95909 and 95886. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 95909 and 95886 are not supported in the medical record. Specifically, the technical 
report did not include documentation of nerve conduction studies; for 5-6 studies; therefore, code 95909 cannot 
be verified. The technical report did not include documentation of a complete needle electromyography, per 
each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and 
latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more 
spinal levels (listed separately in addition to code for primary procedure); therefore, code 95886 cannot be verified. Based on this information, we decided that Medicare rules for coverage of codes 95909 and 95886 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 95909 and 95886 
provided on February 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 13, 2022, to 
May 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 13, 2022, to May 
12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (75736, 75774, 99153) provided April 11, 
2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the codes billed are not eligible for payment.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 75736 and 75774 are not supported in the medical record. Specifically, these radiology 
codes are inclusive to code 37243 (a vascular embolization or occlusion, inclusive of all radiological 
supervision and interpretation). Code 99153 is not eligible for separate payment in the facility setting. Based on 
this information, we decided that Medicare rules for coverage of the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (75736, 75774, 99153) 
provided April 11, 2022.