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

 
We decided that the Plan does not have to pre-approve Relese, per sq cm (Q4257). 
 
You asked the Plan to pre-approve Relese, per sq cm. 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 Relese, per sq cm. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the requested Relese is not recommended in the current 
medical literature indicates the following Moh's surgery. 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 Relese, per sq cm have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Relese, per sq cm (Q4257).
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 is receiving the 
appropriate inpatient acute care and is currently unstable for 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 enrollee appears to be improving but is still somewhat unstable and requires 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. The enrollee does not require services at the LTACH that are not already available and 
covered at the current 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 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 a lower extremity revascularization procedure (37229, 
37227, 37228, 37230, 37231, 37233, 37235, 37232, 37225, 37220, 37221, 37224,37226). 
 
You asked the Plan to pre-approve a lower extremity revascularization 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 lower extremity revascularization 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record provided does not document claudication, non-
healing ulcer, or an arterial duplex assessment. The record provided is insufficient to establish the presence of a hemodynamically significant lesion that would support the medical necessity of the requested service at this 
time.  The record provided does not establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. The elements of the coverage criteria are not satisfied.  The requested service is 
not 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 a lower extremity revascularization procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower extremity revascularization procedure (37229, 
37227, 37228, 37230, 37231, 37233, 37235, 37232, 37225, 37220, 37221, 37224,37226).
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. The 
Plan denied your request. The Plan says the notes received do not show the need to transfer the enrollee to a 
different hospital for their continued care. 
 
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 still be somewhat unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available and covered at the current 
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 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 selective catheter placement, arterial system for prostate 
artery embolization (36245, 36246, 36247). 
 You asked the Plan to pre-approve selective catheter placement, arterial system for prostate artery 
embolization. You say that this is medically necessary. The Plan denied your request. The Plan says this 
service is considered experimental and investigational and 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 selective catheter placement, arterial 
system for prostate artery embolization. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the 
enrollee has benign prostatic hypertrophy with lower urinary tract symptoms. The noted diagnosis is not one 
for which coverage is available as enumerated by the national coverage rules. There is insufficient literature to 
support the safety and efficacy, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement, arterial system for prostate artery embolization 
have not been met. Therefore, we decided that the Plan does not have to pre-approve selective catheter 
placement, arterial system for prostate artery embolization (36245, 36246, 36247).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility services. 
 
You asked the Plan to pre-approve continued skilled nursing facility services. The Plan denied your request. 
The Plan says you have exhausted the 100-day Skilled Nursing Facility (SNF) Benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 6, 2023, through 
September 15, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 17, 2023, billed with 
procedure code 96372-XU. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this service is included in the primary 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim.  
STV-packaged services are assigned status indicator Q1. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Code 96372 has a status indicator Q1 and is 
not payable when billed with code 99284. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on March 17, 2023, billed with procedure code 96372-XU.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that Original Medicare covers nasal airway 
remodeling. You also say that this should be approved. The Plan denied your request. The Plan says nasal 
septal swell body (NSB) reduction for the treatment of nasal obstruction is unproven and not medically 
necessary due to insufficient evidence of safety and/or efficacy. 
 
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 VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has nasal obstruction and chronic sinusitis. 
There is insufficient literature to support the safety and efficacy of the requested service for the enrollee's 
specific conditions. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. Therefore, the reviewer found that the request for the 
VivAer 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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810, 95811). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical information provided does not indicate that the enrollee has observed 
apneas, choking, or gasping during sleep, documentation of a neck circumference and a completed and 
abnormal score on the Epworth Sleepiness Scale. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies can be 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 a sleep study. Our reviewer says that 
records in this case do not document all of the required elements for coverage of the test as outlined by the 
Local Coverage Determination (LCD). Our physician reviewer found based on the medical records provided 
there is no documentation that the sleep study at issue in this case meets all Medicare criteria for medically 
reasonable and necessary 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 a sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810, 95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do 
not meet the requirements for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation does not indicate that you use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454). 
 
You asked the Plan to pre-approve the injection of an anesthetic or steroid into the genicular nerve. You say 
that the enrollee underwent her first genicular nerve block with 80% relief for 6 months. The Plan denied your 
request. The Plan says under Medicare guidelines, your request is not medically necessary because based on 
the medical literature this 
procedure is considered experimental or investigational and has not been proven to be beneficial for your 
condition. 
 
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 injection of an anesthetic or steroid into the genicular nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve 
ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, 
including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a 
treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for 
individuals who are not candidates for knee replacement surgery. The review has determined that the requested 
genicular nerve block is considered experimental in nature. 
 
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 injection of an anesthetic or steroid into the genicular nerve have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid 
into the genicular nerve (64454).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt and recline). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the enrollee has been reliant on a 
basic scooter for 90% of their daily mobility and mobility related activities of daily living for the past year or 
more. You say that the enrollee has developed a stage 2 pressure injury on the coccyx. You also say that this is 
due in part from the basic and minimal seating interface on that device, coupled with their declining ability to 
transfer on and off the device. The Plan denied your request. The Plan says the notes do not show that the 
enrollee needs both power tilt and recline. The Plan also says the upgraded electronics are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair may be covered when 
certain 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 a Group 3 power wheelchair. Our 
reviewer says that the requested Group 3 power wheelchair with multiple power options is not medically 
necessary. Our physician reviewer found the provided documentation does not indicate the enrollee has a high 
risk for skin breakdown, use a catheter intermittently, has spasticity, or requires an alternative means of 
managing power drive. Therefore, the reviewer found that the request for a Group 3 power wheelchair 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 a Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (tilt and recline).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service November 21, 2022, 
and November 22, 2022, and code 99239 billed for date of service November 23, 2023. 
 
You asked the Plan to pay for codes 99233 and 99239. You say that medical records were provided. The Plan 
denied your request. The Plan says you did not provide medical records to support these billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of codes 99233 and 99239 have been met. 
Specifically, you only provided medical records for services rendered from November 18, 2022, to November 
20, 2022.  You did not supply any records for the dates of service at issue in this appeal. Therefore, we decided 
that the Plan does not have to pay for code 99233 billed for dates of service November 21, 2022, and 
November 22, 2022, and code 99239 billed for date of service November 23, 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 cannot go to a skilled nursing facility and you 
need to get stronger at an inpatient rehabilitation. The Plan denied your request. The Plan says your records do 
not show that you have complex rehabilitation needs that require frequent evaluation by a rehabilitation 
physician.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 2, 2023, billed with 
procedure codes 96365-59 and 96366-59. 
 
You asked the Plan to pay for the practitioner 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 services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT 
regimen.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The services provided are not payable as this 
is a non-covered service. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on May 2, 2023, billed with procedure codes 96365-59 and 96366-59.