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

 
We decided that the Plan does not have to pre-approve a non-adjunctive, non-implanted continuous glucose 
monitor or receiver (E2103) and supply allowance for non-adjunctive, non-implanted continuous glucose 
monitor (CGM), includes all supplies and accessories, 1 month supply (A4239). 
 
You asked the Plan to pre-approve a non-adjunctive non-implanted continuous glucose monitor or receiver and 
supply allowance. You say that you are appealing the denial as the enrollee is having difficulty managing daily 
fingerstick. The Plan denied your request. The Plan says this request is not medically necessary as the enrollee 
does not meet the criteria. 
 
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 indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a non-adjunctive non-implanted continuous glucose monitor or receiver and supply allowance have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a non-adjunctive, non-
implanted continuous glucose monitor or receiver (E2103) and supply allowance for non-adjunctive, non-
implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply (A4239).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64590 billed for date of service May 6, 2022. You asked the Plan to pay for procedure code 64590. You say that this service was medically necessary and 
should receive separate reimbursement. The Plan denied your request. The Plan says the payment for this 
service is included in the global surgery payment for code 64581, which was performed by this same provider 
on March 16, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that a postoperative period of 90 days applies to major surgeries. The payment for the surgical 
procedure includes payment for all related care provided during the postoperative period. Modifier 79 is used to 
report services performed by the same physician which are unrelated to the initial procedure and therefore 
require separate payment, and modifier 24 is used to report separate evaluation and management services 
performed by the same physician which are unrelated to the initial procedure.  
 
We looked at the file and Medicare rules. This service was performed by the same physician within the 90-day 
global surgery period of another procedure. This service was not billed with an appropriate modifier to indicate 
that it is not related to and therefore not included in the payment for the previous procedure. Although this 
service was reported with the 24 modifier, code 64590 is not an evaluation and management code. This means 
it is inappropriate to use the 24 modifier in this case. Therefore, we decided that the Plan does not have to pay 
for procedure code 64590 billed for date of service May 6, 2022.
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 will benefit from acute inpatient rehab 
services. 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous radiofrequency ablation of the 
basivertebral nerve (Intracept) procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. You also say that the science supporting the safety and effectiveness of 
this procedure is robust. The Plan denied your request. The Plan says this procedure is considered 
investigational for the treatment of vertebrogenic back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is considered experimental as additional research is needed to show the safety and efficacy. Therefore, the reviewer found that the Intracept procedure is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) 
procedure (64628).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for July 5, 2023, to September 2, 
2023. 
 
You asked the Plan to pre-approve home health services. You say that you do not agree with the denial of the 
requested services. 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 the records 
indicate that you are walking at a supervision level with a cane and are able to negotiate a step and access your 
vehicle with stand-by assistance. There are no medical notes provided from your treating physician 
documenting a signed order or need for additional skilled therapy services.  
 
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 for July 5, 2023, to September 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheeled bariatric shower chair (K0108). 
 
You asked the Plan to pre-approve a shower chair. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a wheeled bariatric shower chair 
(K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guidance Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary for the enrollee. The Plan 
denied your request. The Plan says there is not enough evidence that this type of radiation therapy guidance is 
needed or effective for the enrollee's skin cancer. Therefore, it not considered standard of care. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found usually, IGRT is used when critical structures are abutting or in close proximity to the target 
that is being treated to high doses. This situation does not apply to this enrollee for which the target lesion can 
be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280) and/or IGRT 
for a technology for which need has not been established by published data or supported by consensus 
guidelines (many of which recommend against treatment with these devices in general) is not necessary. The 
decision is unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guidance Radiation Therapy (IGRT) (G6001).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral knee arthroplasty with chondroplasty with an 
out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no network deficiency. 
 
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 
a referral knee arthroplasty with chondroplasty with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheter removal surgery provided on February 14, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for catheter removal surgery. You say that this should be covered. The Plan denied 
your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for catheter removal surgery provided on February 14, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is able to ambulate using a walker, and is independent with MRADLs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that this is only covered for assistance with mobility in the home to perform MRADLs. The enrollee is requesting this for 
use outside of the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique rendered on January 14, 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 records do not support the services billed, as the documentation does not support that the 
procedure/service was distinct or independent from other services performed. 
 
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 87640 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Staphylococcus aureus, amplified probe technique." 
 
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 record does not support that 
CPT code 87640 is a separate and distinct procedure from 87641. In this case, 87640 is not supported. 
 
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 infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified 
probe technique rendered on January 14, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient psychiatric hospital services provided from August 9, 
2022, to September 1, 2022.  
 
You asked the Plan to pay for the inpatient psychiatric hospital services. You say that it is felt that this care was 
medically necessary.  The Plan denied your request. The Plan says that the Plan has paid for 94 days of 
inpatient psychiatric care between December 11, 2019, to February 1, 2022. As such, the inpatient psychiatric 
benefit is exhausted.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not proven its assertion that the lifetime 190-day inpatient 
psychiatric benefit had been exhausted as of the date of admission in this case. The Plan has listed several 
hospital stays that it contends were applied to this benefit. Remits were not submitted for all these stays, but 
one of the remittances for a stay beginning on August 24, 2021, which the Plan states contributed 56 days 
toward the limit, was billed through the inpatient prospective payment system via a Diagnosis Related Group 
(DRG), and not as an inpatient psychatric hospital claim. In addition, review of the screenshot from the CWF 
shows that as of the date that the Plan ran the search, on May 30, 2023, the enrollee is listed as having 94 days 
remaining. Based on this information, we find that the benefit limit for these services was not exhausted for 
these dates of service. Therefore, we decided that the Plan has to pay for the inpatient psychiatric hospital 
services provided from August 9, 2022, to September 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the request does not meet Medicare requirements. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this is considered an experimental/investigational procedure. It is the subject of 
ongoing clinical trials.  
 
 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 17, 2023, 
by a non-Medicare eligible provider. 
 
  You asked the Plan to pay for the emergency room services. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says due to the fact that these facilities are not hospitals, 
and are not affiliated with a hospital, they are actually unable to obtain Medicare approval/certification. The 
Plan also says that Medicare guidance allowing for payment on emergent hospital claims for non-Medicare 
certified hospitals does not apply to non-Medicare freestanding emergency facilities, and the claim denied 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. Medicare rules also say that Medicare covers services in an 
emergency department only if the emergency clinic is affiliated with the hospital.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The documentation provided also states that the facility in question is not an actual hospital and has 
no affiliation with a hospital. Therefore, we decided that the Plan does not have to pay for the emergency room 
services provided on February 17, 2023, by a non-Medicare eligible provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right-sided lumbar rhizotomy. 
 
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 submitted physical examination 
does not clearly document right facet pain. There is also 50 percent documented relief from a previous 
procedure. The rhizotomy is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right-sided lumbar rhizotomy.