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

 
We decided that the Plan does not have to pre-approve intensity modulated radiation treatment (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that IMRT is the preferred treatment based on the toxicity 
of the surrounding structures. You say that the enrollee's cancer is fairly manageable, but that if the treatment 
interferes with surround structures the enrollee will suffer in the long run and the condition may not improve. 
You say that risk to surrounding structures could cause unnecessary comorbidities. The Plan denied your 
request. The Plan says there is no documentation in the medical records supporting the special need for IMRT. 
 
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 IMRT. Our reviewer says that IMRT is 
not considered medically reasonable and necessary in this case. Our physician reviewer found the case records 
did adequately demonstrate the need for IMRT using plausible dosimetric evidence (i.e., to what extent IMRT 
reduced the dose-volume exposure of critical normal tissues).  This is important in justifying the need for 
IMRT in clinical scenarios (such as this case) for which IMRT is not standard. Simply asserting that IMRT is 
necessary does not constitute sufficient documentation for medical necessity of IMRT. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation treatment (IMRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on March 
23, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says pneumatic compression devices are 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 (E0676) provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 2 power wheelchair and accessories K0842, 
E1028, E1012, E2311, E2361, E2377, E1007 and E2313. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the requested group 2 power wheelchair 
with accessories is medically appropriate for the enrollee and would allow them to complete their activities of 
daily living independently and assist with additional medical conditions. 
 The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested group 2 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the criteria has not been met for a Group 2 power wheelchair with accessories. The 
enrollee has a mobility deficit that cannot be overcome with a walker or cane due to weakness. The 
documentation does not reveal that the enrollee is unable to use a manual wheelchair for dependent mobility. 
The enrollee has 24/7 caregiver assist.  The documentation does not reveal that the enrollee would be able to 
use the requested power wheelchair safely. A Periscope evaluation notes that a power wheelchair will not 
provide an increase in independence in activities of daily living. The evaluation recommends a manual 
wheelchair with tilt in space, recline, and a skin protection seat to meet dependent mobility and positioning 
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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Group 2 power wheelchair and accessories K0842, E1028, E1012, E2311, 
E2361, E2377, E1007 and E2313.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22633, 69990, 76000 and 22830 billed for 
date of service May 21, 2021. 
 
You asked the Plan to pay for procedure codes 22633, 69990, 76000 and 22830. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says code 22633 is not supported as 
billed, and the payment for codes 69990, 76000 and 22830 would be included in the payment for other services 
billed on this claim. 
 
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 codes 22830 and 76000 are both column II codes to column I code 22633. 
These services have not been billed with an appropriate modifier to bypass the edit. We have also confirmed 
that code 69990 is a column II code to column I code 22830 with a modifier indicator of 0. The column II code 
is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met for codes 
22830, 76000 and 69990. 
 
In addition, the CPT Code Manual definition of code 22633 is arthrodesis, combined posterior or posterolateral 
technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare 
interspace (other than for decompression), single interspace, lumbar. 
 
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 procedure code 22633. Our reviewer says that CPT code 
22633 is not supported by the documentation provided. Our reviewer found the procedure report states that a 
previous fusion was performed during a prior surgery, and this current procedure was performed to evaluate it. 
No new arthrodesis was performed during this encounter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 22633, 69990, 76000 and 22830 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 22633, 69990, 76000 and 22830 billed for 
date of service May 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the somatosensory testing (codes 95938 and 95927) provided 
on May 10, 2022. 
 
You asked the Plan to pay for the somatosensory testing. You say that medical necessity is supported for the 
procedures performed, and you would like this claim to be reprocessed. The Plan denied your request. The Plan 
says charges for or in connection with services or supplies that are considered to be experimental or 
investigational are excluded from coverage under the enrollee's plan. 
 
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 pay for the somatosensory testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found multimodal intraoperative neurophysiological monitoring (MIONM) has the 
advantage of compensating for the limitations of each individual technique and seems to be effective and 
accurate for detecting perioperative neurological injury during spine surgery. Although there are no prospective 
studies validating the efficacy of intraoperative neurophysiological monitoring, there is a growing body of 
evidence supporting its use during spinal surgery. Our reviewer found that the lack of validated protocols to 
manage intraoperative alerts highlights a critical knowledge gap. Future investigation should focus on 
developing treatment methodology, validating practice protocols, and synthesizing clinical guidelines. Our 
physician reviewer also found that the somatosensory testing at issue in this case was not 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 the somatosensory testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the somatosensory testing (codes 95938 and 95927) provided on May 10, 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, and 
enrollee's needs cannot be met at a lower level of care. The Plan denied your request. The Plan says member 
does not meet the Medicare criteria for an IRF admission. 
 
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 clinical documentation does not specify any active medical comorbidities or 
complex functional impairments; Thus, the complexity of the enrollee's documented nursing, medical and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. IRF criteria not 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 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 the electrical stimulator (E0730), provided on August 10, 
2022. 
 
You asked the Plan to pay for the electrical stimulator. You say that the item was medically necessary. The 
Plan denied your request. The Plan says proper documentation was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication the ordered item was discussed or needed in the medical records submitted. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator (E0730), provided on 
August 10, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric. 
 
You asked the Plan to pre-approve Monoferric. You say that the requested drug is medically necessary for 
treatment of the enrollee's iron deficiency anemia. The Plan denied your request. The Plan says the enrollee has 
not tried and failed the preferred step therapy drug and there is no indication that the preferred drug would 
likely be less effective or cause adverse effects for the enrollee. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Monoferric. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Venofer 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. 
There is no documentation provided indicating that the Plans required drug would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex device. 
 
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 requested Coflex device is 
considered experimental in nature, as more research is needed to show its safety and effectiveness. The services 
are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that failure to place the enrollee on the proper therapy 
will result in future re-admissions and poor quality of life. The Plan denied your request. The Plan says a 
ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide CPAP or 
BiPAP therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan had access to records from an office visit from 2/14/23. The actual 
records from this visit were not provided, only the summary from an internal plan system. Therefore, we 
decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88172, 88173, 88305) provided on April 
15, 2022. 
 
You asked the Plan to pay for pathology services. You say that the primary diagnosis on this claim is valid and 
appropriate. The Plan denied your request. The Plan says two of the diagnoses submitted on this claim cannot 
be billed together per Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that an Excludes1 is used when two conditions cannot occur together, such as a congenital form 
versus an acquired form of the same condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare billing rules 
have not been met. Specifically, this claim was submitted with diagnosis codes R22.1 and R93.89. However, 
codes within the R22 code set have an Excludes1 note for codes within the R90-R93 range. This means that 
codes R22.1 and R93.89 cannot be reported together. Based on this information, we decided that Medicare 
rules for coverage of pathology services have not been met. Therefore, we decided that the Plan does not have 
to pay for pathology services (88172, 88173, 88305) provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound image-guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve the US-IGRT. You say that you have cancer on your nose and the requested 
treatment is medically necessary. The Plan denied your request. The Plan says ultrasound imaging is not 
recommended for staging, diagnosis, or to assess treatment response. The Plan says that ultrasound images are 
not supported for the use of radiation therapy dose prescription decisions. 
 
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 US-IGRT. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device 
itself is approved by the Food and Drug Administration (FDA) for use with ultrasound, though that in and of 
itself does not mean that daily imaging is necessary but simply that the device was designed to incorporate this 
functionality. Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has 
not been established by published data or supported by consensus guidelines is not 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 US-IGRT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound image-guided radiation therapy (US-IGRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 73502 billed for date of service September 
21, 2022. 
 You asked the Plan to pay for procedure code(s) 73502. You say that there is no modifier required for this 
service. The Plan denied your request. The Plan says this code is included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 73502 has a Professional/Technical indicator of 1. This means that CPT code 73502 has 
both a professional and technical component. In this case, CPT code 73502 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 73502 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 73502 billed for date of service September 21, 2022.