Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the omental flap (49905) provided on September 20, 2021. 
 
You asked the Plan to pay for the omental flap (49905). You say that per the certified coder, the records 
document code 49905. The Plan denied your request. The Plan says procedure code 49905 is not supported by 
the medical records submitted. 
 
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 49905 is omental flap, intra-abdominal (List separately in 
addition to code for primary procedure). 
 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the omental flap (49905). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report describes robotic assisted procedures performed. The operative report does not include 
enough documentation to confirm the criteria for an intra-abdominal omental flap. Therefore, this procedure 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the omental flap (49905) have not been met. Therefore, we decided that the 
Plan does not have to pay for the omental flap (49905) provided on September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for this device is correct, because a ventilator is not covered 
when used to provide positive airway pressure and your needs could be met with a bi-level positive airway 
pressure (BiPAP) with average volume assured pressure support (AVAPS) mode instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators are not covered when used to provide 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition.  
 
We looked at the file and Medicare rules. A ventilator is not covered for the requested purpose. The Plan says 
that you needs can be met by a BiPAP device with AVAPS mode instead. Please contact the Plan for more 
information about your treatment options. 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 a 
portable ventilator.
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 you are requesting an LTACH versus a 
short-term acute care for the enrollee, as you expect she will require another 3 to 4 weeks to continue weaning 
from their current level of respiratory support and to transition from her acute illness. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to 
an LTACH. 
 
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 patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be considered 
when treatment has completed.  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62321). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that due to lacking and insufficient medical records, illegible medical 
records, and missing information regarding pain and conservative treatments, the denial should be upheld. 
 
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 requested services are not considered medically reasonable and necessary in this case. There is no history of 
your pain, medications tried, therapies attempted, or any such details listed in the submitted records. There is 
no discussion about the pain itself and how it presented. There are no records of you suffering from any deficits 
from your stated diagnosis. Our physician reviewer found that your condition does not meet criteria for 
coverage of these services. 
 
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 epidural steroid injection (62321).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Facet Injection, Lumbar/Sacral, a shot of pain 
numbing substance in one level of the lower back using imaging guidance or detailed pictures to diagnose or 
treat pain (64493,64494). 
 
You asked the Plan to pre-approve the Facet Injection. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the primary indication of a diagnostic facet joint 
procedure is to diagnose whether the patient has facet syndrome. Intra-articular (IA) facet blocks are considered 
medically reasonable and necessary as a diagnostic test only if MBB cannot be performed due to specific 
documented anatomic restrictions or there is an indication to proceed with therapeutic intra-articular injections. 
These restrictions must be clearly documented in the medical record and made available upon request. 
Diagnostic procedures should be performed with the intent that if successful, an RFA procedure would be 
considered the primary treatment goal at the diagnosed levels. 
 
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 Facet Injection. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the physician does not detail whether 
or not an RFA procedure will be considered after treatment of MBBs. It is noted the medical records are clear 
that the plan is to follow-up with more blocks for the member's right lower extremity pain. However, there is 
no mention of an RFA. As given in the listed guidelines, the purpose of the MBB, diagnostically, is to end with 
an RFA being the primary treatment. There is no indication from the submitted medical records that this is the 
plan. 
 
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 Facet Injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Facet Injection, Lumbar/Sacral, a shot of pain numbing substance in one level of 
the lower back using imaging guidance or detailed pictures to diagnose or treat pain (64493,64494).
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that 
the therapy needed does not need to be done in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found 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 was admitted for chemotherapy for leukemia. The enrollee's medical problems are stable. 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. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9954) and removable appliance 
therapy (D8210). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee requires a night guard due to 
bruxism. You also say that they require a retainer for their lower teeth which are moving. The Plan denied your 
request. The Plan says the requested services were denied correctly. 
 
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, the requested occlusal guard and 
removable appliance therapy are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve an occlusal guard (D9954) and removable appliance therapy (D8210).
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. The Plan denied your request. The Plan says the 
criteria for an LTACH are not met. The Plan also says that there is no documentation that the enrollee needs 
frequent care that cannot be given in a less intensive setting. 
 
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 patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to 
an LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be considered 
when treatment has completed. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the clinical information provided 
supports the need for the CardioMEMS device. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer 
says that the CardioMEMS device is 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 patients 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 2, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not submitted with a valid type 
of bill code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, Specifically, 
this claim was not submitted with an appropriate type of bill code for home health services. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on July 19, 2021. 
 
You asked the Plan to pay for the occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report 
provided on December 5, 2021, billed with code 93010. 
 
You asked the Plan to pay for the EKG as billed. You say that this should be paid. The Plan denied your 
request. The Plan says this was not billed with a required modifier.  
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 93010 
is a column II code to column I code 36556. 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 the electrocardiogram (EKG) interpretation and report provided 
on December 5, 2021, billed with code 93010.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease (ESRD)-related laboratory testing 
provided on August 4, 2021. 
 
You asked the Plan to pay for the ESRD-related lab testing. You say that this should be separately paid. The 
Plan denied your request. The Plan says lab testing for ESRD patients is included in payment made to the 
facility. 
 
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 
end-stage renal disease (ESRD)-related laboratory testing provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve permanent facial hair removal. 
 
You asked the Plan to pre-approve permanent facial hair removal. You say that you need to see a transgender 
specific provider for proper care and treatment for your condition. The Plan denied your request. The Plan says according to Medicare guidelines, permanent removal of facial hair is considered cosmetic for 
the transgender care purposes and is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that hair removal/ hair transplantation is considered 
cosmetic for the treatment of gender dysphoria and 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 permanent facial hair removal. Our 
reviewer says that permanent facial hair removal does not meet the Medicare LCA coverage criteria. Our 
physician reviewer found that the Medicare local coverage article enumerates the conditions and limitations of 
coverage for the requested service and states, in relevant part, that services that are considered cosmetic, 
including hair removal, for the treatment of gender dysphoria are not covered. In this case, the record indicates 
that you seek permanent facial hair removal as part of gender reassignment. By rule, coverage is not available 
for the requested service. The elements of the Medicare 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 permanent facial hair removal have not been met. Therefore, we decided that 
the Plan does not have to pre-approve permanent facial hair removal.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lmpediMed's L-Dex device (CPT code 93702). 
 
You asked the Plan to pre-approve the service. You say that you are at high risk of developing lymphedema, 
and you believe the use of lmpediMed's L-Dex device is medically necessary. You state that you are 
requesting four (4) visits since you will be returning quarterly according to the provider's lymphedema 
prevention protocol. The Plan denied your request. The Plan says this test has not yet been shown to be better 
than standard tests. 
 
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 use of bioimpedance spectroscopy for lymphedema is unproven and is not medically 
necessary due to insufficient evidence of safety and/or efficacy. The review has determined that the 
items/services at issue in this case are 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lmpediMed's L-Dex device (CPT code 93702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation (D0367) and a surgical access to an implant body (D6011). 
 
You asked the Plan to pre-approve the cone beam CT capture and interpretation and surgical access to an 
implant body. You say that the implant procedure was started on December 7, 2021 and at that time 100% of 
the procedure was covered under your plan. You also say that since the procedure was already started, you 
would like these services to be covered. The Plan denied your request. The Plan says these services are not 
covered under your plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam computed tomography (CT) capture and interpretation (D0367) and a surgical access to an implant 
body (D6011).