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

 
We decided that the Plan does not have to pre-approve eCoin peripheral nerve stimulation (PNS).  
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 PNS for urinary incontinence is covered when 
specific criteria are met. 
 
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 records do not show that the stress 
incontinence has been addressed adequately for this enrollee. The records show that Gemtesa has helped, but 
she ran out. The records do not show that the enrollee has tried any other medications for urge incontinence. 
eCoin is considered to be an experimental treatment for overactive bladder (OAB) and the American 
Urological Association (AUA) is currently reviewing its guidelines on the treatment of OAB to consider 
whether eCoin neuromodulation should be added as a recommended treatment option. The services are 
therefore not reasonable or medically necessary at this time. 
 
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 eCoin peripheral nerve stimulation (PNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided 
from March 21, 2023, to April 12, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) is 
not covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pay for a fluid circulating cold pad with pump (E0218) provided from March 21, 2023, to April 12, 
2023.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current 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 enrollee appears to be improving but still somewhat unstable and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care soon. The enrollee does not require services at the 
LTACH that are not already available at the current facility. Completion of treatment at the current facility is 
recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 enrollee has chronic respiratory 
failure due to chronic obstructive pulmonary disease (COPD). The ventilator is being requested for use in an 
average volume assured pressure support (AVAPS) mode which is a modality that could be provided by a 
bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. Medicare does not cover the 
ventilator for this use. 
 
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 home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing and validity testing billed for date(s) of 
service May 24, 2023.  
 
You asked the Plan to pay for the services. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says the services are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. Medicare rules also say that 
the physician must clearly document, in the medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, we find that the testing described by code 
83789 is not separately payable. Additionally, the documentation submitted does not contain a valid physician 
order or lab requisition for the drug testing provided in this case. Therefore, we decided that the Plan does not 
have to pay for the drug testing and validity testing billed for date(s) of service May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80053 billed for date of service March 27, 
2023. 
 
You asked the Plan to pay for the billed service. You say that physicians send specimens for testing. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 80053 is comprehensive metabolic panel. This panel 
must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide 
(bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) 
Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) 
Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) 
 
We find that CPT code 80053 is not supported in the medical record. Specifically, the results of the panel do 
not include all of the required tests. Based on this information, we decided that Medicare rules for coverage of 
the billed service have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 80053 billed for date of service March 27, 2023.
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 you are having a difficult time walking and are 
having some falls. The Plan denied your request. The Plan says you do not meet the criteria for admission to 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 there are no acute rehab skilled nursing needs identified or documented. At the 
current functional level, you need routine physical and occupational therapy services. IRF Admission is not 
necessary and reasonable. Your rehab needs can be provided in an alternate and low intensity setting such as 
continued in an skilled nursing 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 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 (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically necessary 
for use after surgery. The Plan denied your request. The Plan says this item is not covered. 
 
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).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97530, 97162 and 97110) billed for 
date of service June 26, 2023. 
 
You asked the Plan to pay for therapeutic services. You say that these services and conditions were reported 
appropriately. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R39.15 has an Excludes1 note in relation to N39.41. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for therapeutic services have not been met. Therefore, we decided that the Plan does not have to 
pay for therapeutic services (97530, 97162 and 97110) billed for date of service June 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ferumoxytol (Q0138). 
 
You asked the Plan to pre-approve ferumoxytol. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the records do not show that the enrollee has trialed oral iron 
supplements. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 ferumoxytol. Our reviewer says that the 
request for ferumoxytol is not medically necessary. Our physician reviewer found the requested use of 
ferumoxytol FDA-approved for the enrollees diagnosis. The requested use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal either. The 
reviewer also found that the enrollee has not been documented to have a trial or oral iron or medical issues that would preclude a trail of oral iron. Therefore, the reviewer found that the requested use of ferumoxytol 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 ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ferumoxytol (Q0138).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of thorax. 
 
You asked the Plan to pre-approve CT scan of thorax. You say that this is medically necessary based on having 
pulmonary nodules. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of thorax. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does not meet criteria for 
a low dose screening CT scan of the chest. She already had an abnormal CT angiogram which showed 
pulmonary nodules. The appropriate follow-up study would be a repeat CT angiogram of the chest, not a 
screening study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of thorax have not been met. Therefore, we decided that the Plan does 
not have to pre-approve CT scan of thorax.
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 SNF admission is necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for the SNF admission. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 19, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on July 19, 2023, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis, posterior or posterolateral technique, 
single interspace; lumbar (22612) using a Watchman device. 
 
You asked the Plan to pre-approve the Watchman device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says use of this device as a stand-alone procedure has not 
been shown to be safe and effective in long term studies. 
 
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 Watchman device. Our reviewer 
says that the requested Watchman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. In addition, there are multiple alternate pain generators plausibly significantly contributing to the clinical condition that have not been fully documented as having 
been excluded and/or ruled out. No compelling rationale is presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Minuteman device for 
posterior lumbar arthrodesis 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 the Watchman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an arthrodesis, posterior or posterolateral technique, single interspace; lumbar 
(22612) using a Watchman device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says this is considered 
experimental and therefore is not covered. 
 
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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The reviewer also found that the documentation does not indicate a clear cause for the enrollee's pain. Therefore, the reviewer found that the requested Intracept 
procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vivistim Paired Vagusnerve stimulator (64568). 
 
You asked the Plan to pre-approve a Vivistim Paired Vagusnerve stimulator. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vivistim Paired Vagusnerve 
stimulator. 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 there is no 
documentation that the vagus nerve stimulator at issue in this case meets all Medicare criteria for medically 
reasonable and necessary and safe and effective for you. Provided medical records and review of the current peer-reviewed medical literature do not document that use of the vagus nerve stimulator has been shown in 
controlled studies in a CMS-approved journal to result in long term health benefits in patients with monoplegia 
of the left upper extremity due to a stroke. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vivistim Paired Vagusnerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vivistim Paired Vagusnerve stimulator (64568).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 8, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 8, 2023.