Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service and the lumbar x-ray provided on 
April 03, 2023. 
 
You asked the Plan to pay for the laboratory service and the lumbar x-ray. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory service 
and the lumbar x-ray provided on April 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total knee replacement surgery and self-administered 
drugs provided in an outpatient setting from April 11, 2023, to April 17, 2023. 
 
You asked the Plan to pay for the outpatient surgery and self-administered drugs. You say that you received a 
bill for $39,612. You say that you had a reaction to the anesthesia and needed to say in the hospital for six days. 
You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. The Plan also says that self-administered drugs provided in an outpatient setting 
are not covered under Medicare Part B. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for Outpatient surgery. The rules also say that Medicare Part B generally does not pay for self-
administered drugs. 
 
You have been asked to pay a $295 copayment for the total knee replacement surgery. This service falls within 
the Outpatient surgery benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Additionally, the self-administered drugs in this case are not among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay any additional amount 
for the total knee replacement surgery and self-administered drugs provided in an outpatient setting from April 
11, 2023, to April 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on April 13, 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 Current Procedural Terminology (CPT) code 99223-AI (1 Unit) remains 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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 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 medical records do not 
support this level of medical decision making or have the appropriate documentation of time spent. 
 
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 evaluation and management services (procedure code 99223) rendered on April 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital inpatient or observation care (99222) 
provided on June 12, 2023. 
 
You asked the Plan to pay for the physician service. You say that this should be covered. The Plan denied your 
request. The Plan says you cannot receive two initial evaluation and management visits from a single provider 
during a single hospitalization. 
 
The Plan must follow Medicare rules. Medicare rules say that initial observation care codes are paid for care 
rendered by the order physician on the date the patients observation services began. The rules say that other 
physicians who furnish additional evaluations or services while the patient is receiving observation services 
must bill the appropriate outpatient service codes.  
 
The records provided do not support that the initial observation care code in dispute (99222) was billed for services provided by the physician who ordered the enrollees admission, nor was it billed for the date that the 
enrollees observation services began. Therefore, we decided that the Plan does not have to pay for the initial 
hospital inpatient or observation care (99222) provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G powered upper extremity range of 
motion assist device, elbow, wrist, hand, finger, single or double upright(s) (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G device. You say that this is necessary for those with 
chronic upper extremity muscle weakness or partial paralysis who have exhausted all conventional therapies 
and reached their maximum therapeutic benefit. The Plan denied your request. The Plan says it is not clear that 
this device will help the enrollee complete daily activities. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro Motion G device. Our 
reviewer says that the requested MyoPro Motion G device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found he MyoPro Orthosis is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro 
is not the standard of care for the enrollee's condition or in widespread use for the enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for the enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. Therefore, the reviewer found that the requested MyPro Motion G 
device 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 MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G powered upper extremity range of motion assist device, 
elbow, wrist, hand, finger, single or double upright(s) (L8702).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Heelex low dose external beam radiation therapy (77290, 77280, 
77331). 
 
You asked the Plan to pre-approve radiation therapy. You say that the requested therapy is medically necessary 
due to primary osteoarthritis of the right ankle and foot. The Plan denied your request. The Plan says that the 
request for radiation treatment for this enrollee's right foot pain is not approved. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 radiation therapy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of radiotherapy to treat arthritis dates back many decades and is commonly practiced in 
Germany and other European countries. While radiotherapy is not commonly utilized for arthritis in the United 
States (US), it is an effective treatment for which many US doctors (who would refer for radiation) are 
unfamiliar. However, it is an accepted standard for osteoarthritis that is resistant to less invasive therapies (i.e., 
medical management, steroid injections). From Evicore guidelines: Degenerative skeletal disorders, radiation 
therapy may be used for symptomatic degenerative skeletal and joint disorders (i.e., plantar fasciitis, 
trochanteric bursitis) that are refractory to conventional methods. For plantar fasciitis, for example, 1 gray (Gy) 
per week for 6 weeks was associated with a response rate approaching 80% and durable at 48 weeks. Using 
conventional isodose technique, up to 8 fractions is considered appropriate. Radiation for treatment-resistant 
osteoarthritis, based upon published literature and guideline statements (from Germany) would be considered 
to be furnished with accordance of accepted standards of care and therefore, the decision is favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to pre-
approve Heelex low dose external beam radiation therapy (77290, 77280, 77331).  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee brace (L1846). 
 
You asked the Plan to pre-approve a knee brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says that the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a knee brace is covered with the criteria listed in the 
Medicare Rules section is 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 knee brace. Our reviewer says that the 
item is medically necessary. Our physician reviewer found the enrollee is ambulatory, has knee instability due 
to a ICD-10 group 4 diagnosis code (knee arthritis), with supportive physical exam as documented in the x-ray 
findings, and she cannot be fit with prefabricated brace alternatives given her size. 
 
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 knee brace have been met. Therefore, we decided that the Plan has to pre-
approve a knee brace (L1846).   
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation of the nerves of the sacroiliac 
joint (64625). 
 
You asked the Plan to pre-approve a radiofrequency ablation of the nerves of the sacroiliac joint. You say that 
the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested services are experimental/investigational. 
 
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 radiofrequency ablation of the nerves 
of the sacroiliac joint. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that radiofrequency ablation of the lateral sacral 
branches is considered experimental due to the wide variation in efficacy reported in the medical literature.  
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 radiofrequency ablation of the nerves of the sacroiliac joint have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation of the nerves of the 
sacroiliac joint (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (procedure code E1399) rendered on May 22, 2023. 
 
You asked the Plan to pay for the services. You say that this is needed to do routine daily functions. The Plan 
denied your request. The Plan says correct coding policy indicates that the appropriate code must be submitted. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code E1399 is "Durable medical equipment, miscellaneous." 
 
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 medical record does not 
include documentation of a delivery ticket with the durable medical equipment (DME) provided on this date of 
service. The documentation is insufficient to support this code. 
 
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 orthotics (procedure code E1399) rendered on May 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee 
has restless legs syndrome which would benefit from having iron levels above 75, and in severe cases above 
100. His last iron level was reported to be 65, which is within the normal range. There is no documentation 
provided of the enrollees hemoglobin and hematocrit. There is also no documentation to support a diagnosis of 
iron deficiency anemia. The dcumentation does not support that Injectafer is medically reasonable and 
necessary for the enrollee. The documentation does not support that Injectafer is safe and effective 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
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 cannot find a ramp that is suitable for you to get 
in and out of the house. You say that you do not think it is safe to go with options that you were given and that 
you need to get a little stronger to use the handicap gear that you have. The Plan denied your request. The Plan 
says continued SNF care is no longer required. 
 
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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require 
daily skilled nursing 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual, the medical record 
overall significantly complies with the various documentation requirements for IRF admission (e.g., as best 
summarized by the therapy and hospitalist notes from October 25, 2023, as well as the home nursing evaluation 
from October 30, 2023).  This enrollees condition is in fact complex and fragile, and there is every reason to 
expect that they will participate in and benefit from IRF level 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 EsoGuard testing (0114U) provided on June 28, 2023. 
 
You asked the Plan to pay for the EsoGuard testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The genetic testing in this case is not covered per the DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
EsoGuard testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
EsoGuard testing (0114U) provided on June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Blatchford Linx System Knee and Foot. 
 
You asked the Plan to pre-approve a Blatchford Linx System Knee and Foot. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the requests exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Blatchford Linx System Knee and 
Foot. Our reviewer says that the item is medically necessary. Our physician reviewer found the medical records 
submitted indicate this enrollee is a K3 ambulator and requires the requested parts. 
 
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 Blatchford Linx System Knee and Foot have been met. Therefore, we decided 
that the Plan has to pre-approve a Blatchford Linx System Knee and Foot.  
 
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.