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

 
We decided that the Plan does not have to provide reimbursement for the IntraDiscNutrosis spinal treatments 
provided from January 24, 2023, through April 28, 2023. 
 
You asked the Plan to provide reimbursement for the spinal treatments. You say that you believe that this 
should be covered.  The Plan denied your request. The Plan says these services are not covered by Medicare.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
Review of the provider at the office at issue shows that he is a chiropractor. The records show that the service 
at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to provide 
reimbursement for the IntraDiscNutrosis spinal treatments provided from January 24, 2023, through April 28, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 4, 2021.  
 
You asked the Plan to pay for the lab services. You say that because these services occurred during the 
pandemic, and extension should be granted. The Plan denied your request. The Plan says you did not timely file 
your claim. The Plan follows Medicare rules. The rules say that claims for services furnished on or after 
January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a 
claim for the lab services was not filed until April 20, 2023. This means that more than one calendar year from 
the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to 
pay for lab services provided on January 4, 2021.
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 enrollee needs inpatient rehabilitation after 
suffering a fall and fracturing multiple bones. You say without inpatient rehabilitation therapy, the enrollee will 
not be able to regain full function or mobility. The Plan denied your request. The Plan says the IRF services 
you are requesting do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart cardiac contractility modulation 
(CCM) system (0408T). 
 
You asked the Plan to pre-approve the CCM. You say that the enrollee suffers from a high burden of symptoms 
as a result of chronic heart failure. You say that the enrollee is not indicated for any other approved therapy at 
this time. You also say that without this device, the enrollee's prognosis remains poor. The Plan denied your 
request. The Plan says the clinical value and effectiveness of this device has not been demonstrated in the peer-
reviewed literature. 
 
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 CCM. Our reviewer says that the 
requested CCM system is not considered medically reasonable and necessary in this case. Our physician reviewer found CCM remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, the reviewer found 
that the requested CCM 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 CCM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Optimizer Smart cardiac contractility modulation (CCM) system (0408T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the goal is to reduce the enrollee's 
hospitalizations due to heart failure. The Plan denied your request. The Plan says the use of this device is 
considered experimental and therefore is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a lack of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer 
found that the requested CardioMEMS is 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves 
(64624). 
 
You asked the Plan to pre-approve RFA of the genicular nerves. 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 RFA of the genicular nerves. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental. It is the subject of ongoing 
clinical trials. Therefore, 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 RFA of the genicular nerves have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves (64624).
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 it is not safe for the enrollee to be discharged home. 
You also say that the enrollee's condition meets full inpatient acute rehab criteria which a lower level of care 
such as subacute rehabilitation or home health cannot provide. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in a lower level of care. 
 
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 provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant with skin graft with an out-of-
network provider.  
 
You asked the Plan to pre-approve the outpatient procedure. You say that the providers listed in the denial 
letter all refer patients to the requested doctor because they do not perform this specific surgery. You also say 
that there are no other providers in the network to do the surgery. The Plan denied your request. The Plan says 
there are network providers available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 cochlear implant with skin graft to be 
provided out-of-network. Our reviewer says that the request for a cochlear implant is not medically necessary. 
Our physician reviewer found the record indicates that the enrollee has sensorineural hearing loss. The Plan has 
indicated that there are in-network providers who are available and capable of providing the requested service.  
The record provided does not documents any unique characteristics about the enrollee's condition that that 
would make it medically necessary for the enrollee to see the requested out-of-network provider. Therefore, the 
reviewer found that the requested outpatient procedure to be provided out-of-network is 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 cochlear implant with skin graft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a cochlear implant with skin graft with an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous revascularization (37230, 37231, 37229, 
37228, 37227, 37226, 37225, 37224, 37221, 37220). 
 
You asked the Plan to pre-approve percutaneous revascularization. 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 percutaneous revascularization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support the medical necessity of the treatments 
in question. There is documentation of left extremity ulcer, and a preoperative left lower extremity duplex was performed. The enrollee is status post angiography with intervention on the left lower extremity twice recently 
with documentation of a successful result. There is no documentation demonstrating failure and need for 
additional procedures on the left. With respect to the right, there is no documentation of a significant issue on 
the right that would necessitate intervention. Additionally, at the time of the lower extremity duplex, the left leg 
was evaluated but not the right suggesting no significant issue on the right at that time. There is no 
documentation that any issue on the right has developed in the interim. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous revascularization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve percutaneous revascularization (37230, 37231, 37229, 37228, 37227, 
37226, 37225, 37224, 37221, 37220).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87641 and 87798 (x13) billed for date of 
service February 15, 2023. 
 
You asked the Plan to pay for procedure codes 87641 and 87798 (x13). You say that these services were 
necessary and are supported as billed The Plan denied your request. The Plan says these codes are not 
supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87641 and 87798 (x13). Our reviewer says 
that these codes are not supported in the provided records. Our reviewer found the laboratory report does not 
include documentation of staphylococcus aureus, methicillin resistant procedure (87641). In addition, the laboratory report does not include sufficient documentation to verify 13 units of "not otherwise specified" 
testing code (87798). Therefore, these codes were denied appropriately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87641 and 87798 (x13) have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87641 and 87798 (x13) billed for date of service 
February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen (E0431) and an oxygen concentrator 
(E1390). 
 
You asked the Plan to pre-approve portable oxygen and an oxygen concentrator. You say that the enrollee has 
severe pulmonary hypertension, heart failure, severe chronic obstructive pulmonary disease (COPD) and she 
will require life-long oxygen dependence to continue any type of quality of life. The Plan denied your request. 
The Plan says oxygen rentals are allowed for up to 36 months. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime for oxygen 
equipment is 5 years.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable oxygen and an oxygen concentrator have not been met. The records show the enrollee 
received her current oxygen and oxygen concentrator on March 25, 2020. The oxygen and concentrator 
equipment are limited to 36 months of rental payments. Specifically, the supplier who provided the equipment 
during the 36th rental month is required to continue to provide the equipment, accessories, contents (if 
applicable), maintenance, and repair of the oxygen equipment during the 5-year reasonable useful lifetime of 
the equipment. Therefore, we decided that the Plan does not have to pre-approve portable oxygen (E0431) and 
an oxygen concentrator (E1390).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult day care services (S5102). 
 
You asked the Plan to pre-approve adult day care services. You say that the enrollee will medically benefit 
from attending an adult day care where he receives both physical and cognitive stimulation/therapy with group 
activities and exercises. The Plan denied your request. The Plan says custodial care is not a covered benefit by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of adult day care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve adult 
day care services (S5102).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11044 and 11047 rendered on February 3, 
2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support the separate reporting of CPT 11044 and CPT 11047. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records indicate that CPT 
28005 - incision and drainage of the bone - was performed on February 3, 2023, on the same anatomical site as 
CPT 11044 and CPT 11047. These codes are inclusive to CPT 28005. Based on the operative note, it would be 
inappropriate to use modifier -59 to unbundle this service. Additionally, CPT 11047 is an add-on code.  An 
add-on code is only eligible for reimbursement consideration if it's primary code is deemed payable. In this 
case, CPT 11044 is the primary code and is not eligible for reimbursement, therefore CPT 11047 does not 
qualify for reimbursement consideration. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 11044 and 11047 rendered on February 3, 2023.
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 is the level of care needed at 
this time.  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 can continue to receive the acute care 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
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 the pneumatic compression device (E0676).