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

 
We decided that the Plan does not have to pre-approve a MyoPro Upper Extremity orthosis. 
 
You asked the Plan to pre-approve a MyoPro Upper Extremity orthosis. 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 MyoPro Upper Extremity orthosis. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis 
will improve the long term outcome for you. There is insufficient evidence in the literature that this device will 
increase  participation in bimanual activities.  
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 MyoPro Upper Extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Upper Extremity orthosis.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 genetic testing provided on November 3, 2022.  
 
You asked the Plan to pay for the Guardant360 genetic testing. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the date of service is not appropriate. It should be reported as the 
date that the specimen was collected.  
 
The Plan must follow Medicare rules. Medicare rules say that the DOS for molecular pathology tests should be 
reported as the date the testing was performed, rather than the date the specimen was collected. 
 
We looked at the file and Medicare rules. We find that the Plan has not correctly applied the billing rules 
regarding the DOS for molecular pathology services. Based on this information, we decided that Medicare 
rules for coverage of the Guardant360 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for the Guardant360 genetic testing provided on November 3, 2022.   
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 that the enrollee does not have documented skilled nursing or skilled therapy needs. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant-at-surgery services related to treatment of a left 
femoral shaft fracture provided on February 1, 2023.  
 
You asked the Plan to pay for the assistant-at-surgery services. You say that this is a service that can be 
covered from a surgical assistant. The Plan denied your request. The Plan says the diagnosis code reported is 
not appropriate for the service. 
 
The Plan must follow Medicare rules. Medicare rules say that ICD-10-CM guidelines must be followed. The 
guidelines indicate that the correct laterality must be reported for conditions which occur on one or both sides of the body. 
 
We looked at the file and Medicare rules. The treatment provided was for the left leg; however, the diagnosis 
code reported was for a right-sided fracture. Based on this information, we decided that Medicare rules for 
coverage of the assistant-at-surgery services have not been met. Therefore, we decided that the Plan does not 
have to pay for the assistant-at-surgery services related to treatment of a left femoral shaft fracture provided on 
February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 Kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 Kyphoplasty (22514). You say that the requested L2 Kyphoplasty is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested L2 Kyphoplasty.  
 
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 L2 Kyphoplasty (22514). Our reviewer 
says that the enrollee does not meet criteria for the requested L2 Kyphoplasty.  Our physician reviewer found 
based on the documentation provided, there is no trial of bracing. More treatment is needed prior to requesting 
this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 Kyphoplasty (22514) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L2 Kyphoplasty (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coinsurance for gauze (A6223), padding bandages 
(A6441), alginate or other fiber gelling dressing, wound cover, sterile, pad (A6196), conforming bandages 
(A6446), and specialty absorptive dressing (A6253) provided from January 19, 2023 to March 1, 2023. 
 
You asked the Plan to pay for the coinsurance for medical supplies. You say that you were advised you would 
not be charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay the 20% coinsurance for the medical supplies. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to pay for the coinsurance for gauze (A6223), padding bandages (A6441), alginate or other fiber gelling 
dressing, wound cover, sterile, pad (A6196), conforming bandages (A6446), and specialty absorptive dressing 
(A6253) provided from January 19, 2023 to March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 April 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 that the enrollee does not require daily skilled nursing or skilled therapy services. The 
enrollee's needs do not require the necessary services on an inpatient basis in a SNF. 
 
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 SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 10, 2022, 
through April 8, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. Review of the file 
shows that the provider did not bill appropriate revenue code with Q code on the claim line 5. Therefore, we 
find that the Medicare rule for payment of this claim has not been met. If the provider determines that a billing 
error occurred during the initial submission, the Plan will accept a submission of a corrected claim to consider 
services for payment. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from March 10, 2022, through April 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried conservative 
treatments with no significant sustainable relief. The Plan denied your request. The Plan says the documents do 
not indicate the enrollee has had both physical and psychological screening by a multidisciplinary team. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging showing only modic changes without 
facet degenerative joint disease or foraminal stenosis. The cause of back pain is not clear.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you cannot keep your balance, and you 
need help in your home. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that it is not 
clear if you are homebound. You do not have documented skilled nursing or skilled therapy 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the records do not show evidence of edema extending 
into the trunk on exam. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD is covered when the criteria listed in the 
Medicare rules section 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 a pneumatic compression device. Our 
reviewer says that this device is not medically necessary. Our physician reviewer found that the documentation 
does not support that the enrollee has failed treatment with a basic lymphedema pump. Additionally, the 
documentation does not support that the enrollee has physical findings consisting of truncal, abdominal or chest 
edema. 
 
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 pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
You asked the Plan to pre-approve a Minuteman procedure. 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 Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a minuteman 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 a Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve irreversible electroporation ablation. 
 
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 use of electroporation is not 
supported by peer-reviewed medical literature and has not been shown in controlled studies in a Medicare-
approved journal to result in long-term benefits in patients with your diagnosis. The services are therefore not 
medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve irreversible electroporation ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Watchman device with inpatient admission.  
You asked the Plan to pre-approve a Watchman device with inpatient admission. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with 
Evidence Development (CED) with certain conditions. 
 
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 Watchman device with inpatient 
admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
guidelines would not support implantation of a LAAC in this setting. LAAC placement would not be 
considered reasonable or medically necessary in the clinical management of this 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 a Watchman device with inpatient admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Watchman device with inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac injection. 
 
You asked the Plan to pre-approve a sacroiliac injection. You say that a sacroiliac injection is medically 
necessary. The Plan denied your request. The Plan says a sacroiliac injection 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 a sacroiliac injection. Our reviewer says 
that the requested sacroiliac injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has had several steroid injections beyond the SI joint and has 
exceeded yearly recommended dosages. The request also exceed SI joint utilization limits. 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 a sacroiliac injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is the best option 
for a safe discharge. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary.  
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The plan has approved ongoing care in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on March 10, 2023, billed 
with procedure codes 99204, 74240, 74230, 92611, 72040, 70100 and 70310. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on March 10, 2023, billed with 
procedure codes 99204, 74240, 74230, 92611, 72040, 70100 and 70310.