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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
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 (E0675).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63015, 22600, and 22614 billed for date of 
service May 1, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the necessity of 
services. The Plan denied your request. The Plan says the billed codes are not supported. 
 
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 63015 is laminectomy with exploration and/or 
decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., 
spinal stenosis), more than 2 vertebral segments; cervical. 
 The definition of code 22600 is arthrodesis, posterior or posterolateral technique, single interspace; cervical 
below C2 segment. The definition of code 22614 is arthrodesis, posterior or posterolateral technique, single 
interspace; each additional interspace (List separately in addition to code for primary procedure). 
 
We find that CPT codes 63015, 22600, and 22614 are not supported in the medical record. The records do not 
show that a laminectomy was performed. The records do show that an arthrodesis procedure was performed, 
but not a posterior technique. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
63015, 22600, and 22614 billed for date of service May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on December 22, 2022, through December 31, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump (E0217) provided on. You say that the 
item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump (E0217) provided on have not been met. Therefore, we 
decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided on 
December 22, 2022, through December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve VIA Disc allograft intervertebral disc augmentation procedure. You say that 
this is medically necessary. The Plan denied your request. The Plan says intradiscal procedures are not 
supported by research and are 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 VIA Disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found further studies are needed to demonstrate 
this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA Disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc 
augmentation procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
power options do not need to be controlled through a joystick.  
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchairs are covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a medical history of a stroke with left sided hemiplegia. Other conditions 
are notable for diabetes mellitus, left sided shoulder fracture, peripheral neuropathy, and lower extremity 
wounds. The enrollee is dependent for toileting, dressing, and bathing. Motor strength in the left upper and 
lower extremities is noted to be 0 out of 5 and 3 out of 5 in the right upper and lower extremities. Sensation is 
impaired. There is a history of skin breakdown. The enrollee is noted to have spasticity in the left upper and 
lower extremities. The complexity of the enrollees seating and positioning needs necessitates a more complex 
group 3 power wheelchair base. The expandable controller with harness and electronic connection are 
necessary to operate the group 3 power wheelchair base and the three power options via a joystick. These 
components are required to operate 3 or more power options on a group 3 power wheelchair and the enrollee 
does not have the coordination to operate them separately. Therefore, the expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) is 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve an expandable control system.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022, billed with 
codes 81194, 81206, 81210, 81272, 81292, 81295, 81298, 81301, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 1, 2022, billed with codes 81194, 81206, 81210, 81272, 81292, 81295, 81298, 81301, and 81317.
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 you are a fall risk and cannot stand up. You also say 
there is no one at home to assist you if you fall. The Plan denied your request. The Plan says continuation of 
SNF services is not medically necessary and does not meet Medicare guidelines.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45381 billed for date of service May 17, 
2023. 
 
You asked the Plan to pay for procedure code 45381. The Plan denied your request. The Plan says payment for 
code 45381 is bundled into payment for code 45382. 
 
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 45381 is a column II code to column I code 45382. The records 
provided only include a pathology report. The medical documentation is not sufficient enough to determine if 
code 45381, billed with the XS modifier, was provided and billed correctly 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 procedure code 45381 billed for date of service May 17, 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 enrollee needs this care to regain 
maximum independence. The Plan denied your request. The Plan says the enrollee's needs can be managed at 
the current facility until they are more stable for transfer to another level of 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's care can be safely provided at the current facility until they are more 
stable and appropriate for transfer to another level of care. 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: 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 and will give the enrollee a maximum opportunity of recovery. The Plan 
denied your request. The Plan says the enrollee is receiving 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. Given there are offered alternatives, 
LTACH is 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 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: 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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does 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 is no active medical complexity. There are no acute rehab nursing needs 
documented. At the current functional level, the enrollee needs routine physical and occupational therapy 
services. Document does not support necessity for admission to an IRF. The complexity of the enrollee's 
medical, rehab, and nursing needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. The enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting such as in a 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: 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 that an LTACH is the appropriate level 
of care, and the enrollee is medically stable to be transferred to the LTACH at this time. You would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that based on the 
Medicare guidelines and the information about the enrollee's condition, the enrollee does not meet all the 
requirements for admission 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 that the enrollee appears to be improving with current treatment but is still not yet stable for transfer and requires additional acute care services that can safely be provided at the current facility 
until more stable and appropriate for transfer. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as the enrollee is not yet stable for transfer and as it would not be clinically advantageous.  
 
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: 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 only option 
for a safe discharge due to the need for frequent nursing care, daily physician management daily labs, physical 
therapy, occupational therapy, and speech therapy. 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. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's requires drugs Venofer and Infed. Also, there is no indication that the Plan's requires drugs would likely 
be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve MRI. You say that the enrollee needs this test. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan and the needed scan can be provided 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) to be provided by an out-of-network (OON) provider.