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

 
We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation procedure 
(64635, 64636). 
 
You asked the Plan to pre-approve radiofrequency ablation injections. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee has only had one set of diagnostic MBBs and 
has not undergone a prior RFA procedure to the same level. The injections are not medically necessary or 
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 radiofrequency ablation injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of low back pain due to lumbar spondylosis. 
Initial diagnostic medial branch blocks (MBBs) at L3-S1 were completed on 5/4/2023. There has not been a 
second confirmatory set of diagnostic MBBs. The enrollee has only had one set of diagnostic MBBs and has 
not undergone a prior RFA procedure to the same level. The requested service 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 radiofrequency ablation injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation procedure (64635, 
64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on November 16, 2022. 
 
You asked the Plan to pay for the office visit (99214). You say that the service should be covered. 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 office visit (99214) 
provided on November 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Doxorubicin, Famotidine, Diphenhydramine, 
and Dexamethasone. 
   
You asked the Plan to pre-approve Keytruda, Doxorubicin, Famotidine, Diphenhydramine, and 
Dexamethasone. You say that the enrollee would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says Keytruda, Doxorubicin, Famotidine, Diphenhydramine and Dexamethasone 
is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda, Doxorubicin, Famotidine, 
Diphenhydramine, and Dexamethasone. Our reviewer says that Keytruda, Doxorubicin, Famotidine, 
Diphenhydramine, and Dexamethasone is not medically necessary. Our physician reviewer found that the use 
of Keytruda, Doxorubicin, Famotidine, Diphenhydramine and Dexamethasone has not been approved by the 
Food and Drug Administration (FDA) approved for the enrollee's diagnosis of endometrial cancer. The use of 
the requested drugs is not supported or recommended in any compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Doxorubicin, Famotidine, Diphenhydramine, and Dexamethasone. 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Doxorubicin, 
Famotidine, Diphenhydramine, and Dexamethasone.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (PCD) provided on January 
20, 2023. 
 
You asked the Plan to pay for the PCD. You say that this PCD was needed to prevent blood clots and should be 
covered.  The Plan denied your request. The Plan says the PCD at issue is not separately payable in this setting. 
 
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 (PCD) provided on January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this request is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage were not met. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the 
provided documentation did not clearly describe the enrollee as having a pressure ulcer in the trunk or pelvic 
area, nor was there evidence of the enrollee being bed bound most of the time or needing frequent position 
changes throughout the day. The enrollee could attach a railing to a stationary regular bed for support and does 
not appear to require special attachments that cannot be utilized in this way. Our reviewer found that therefore, 
without sufficient support made that a semi-electric bed is indicated for this enrollee it will be considered not 
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 a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end stage renal disease (ESRD) services provided on July 
2, 2021, to July 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with an invalid or missing value code. 
 
The Plan must follow Medicare rules. Medicare rules say that all End Stage Renal Disease (ESRD) claims with 
dates of service on or after July 1, 2010, must indicate the applicable Kt/V reading for the dialysis patient. The reading result and the date of the reading must be reported on the claim using the appropriate claim codes.  
 
We looked at the file and Medicare rules. In this case, the claim for ESRD services was billed without the 
required/appropriate value code. 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 the end stage renal 
disease (ESRD) services provided on July 2, 2021, to July 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on November 8, 2022. 
 
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 99285 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 enrollee was evaluated for 
chest pain in the setting of COVID-19 infection. The evaluation was within the standard of care, and the 
medical decision-making was not of high complexity. The enrollee was clinically stable, and the enrollee's 
condition posed no immediate threat to life or function. As such, the billing of CPT 99285 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 emergency department services (procedure code 99285) rendered on November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 15, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acrylic socket identified with code L5629, socket insert 
symes identified with code L5654, molded distal cushion identified with code L5668, and ultra-light material 
below the knee addition identified with code L5785. 
 
You asked the Plan to pre-approve acrylic socket, socket insert symes, molded distal cushion, and ultra-light 
material below the knee addition. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis additions are only covered for certain 
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 acrylic socket, socket insert symes, 
molded distal cushion, and ultra-light material below the knee addition. Our reviewer says that the 
documentation does not support that the requested items are medically reasonable or necessary. Our physician 
reviewer found the enrollee has a past medical history including hypertension, diabetes mellitus and a previous 
partial foot amputation. Potential functional ability is based on the reasonable expectations of the prosthetist, 
and treating practitioner, considering multiple factors. These factors include the enrollee's past history, current 
condition including the status of the residual limb and the nature of the other medical problems and the 
enrollee's desire to ambulate. In this case, the documentation doesnt support that the prosthesis with upgraded 
components is medically necessary for the enrollee with the partial foot amputation. Therefore, the enrollee 
does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acrylic socket, socket insert symes, molded distal cushion, and ultra-light 
material below the knee addition have not been met. Therefore, we decided that the Plan does not have to pre-
approve acrylic socket identified with code L5629, socket insert symes identified with code L5654, molded 
distal cushion identified with code L5668, and ultra-light material below the knee addition identified with code 
L5785.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from August 17, 2022, through 
August 23, 2022, billed with diagnosis codes A41.9, R65.20, and J96.01. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnoses billed were clearly supported and the DRG billed should be paid.  The Plan denied your request. The 
Plan says the DRG correctly reduced due to unsupported diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis 
unspecified organism; and secondary diagnosis codes R65.20, defined as severe sepsis without septic shock, 
and J96.01, defined as acute respiratory failure with hypoxia. 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 pay for the inpatient hospital services at the DRG originally billed. Our reviewer says that the three 
diagnosis codes at issue are not supported by the records. Our physician reviewer found the enrollee presented 
with shortness of breath. She was found to have pneumonia and ruled out for a pulmonary 
embolism. Associated fevers and tachycardia were noted. No evidence of hypotension, hypoperfusion, organ 
failure or hypoxia are noted. As such, the diagnosis codes reported are not appropriate for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient care provided from August 17, 2022, through August 23, 2022, billed with diagnosis codes 
A41.9, R65.20, and J96.01.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the records provided for review did 
not readily support that the enrollee met the diagnostic criteria for either AD or FTD. The enrollees symptoms 
were said to be more consistent with those seen in normal pressure hydrocephalus (NPH). In as much the base 
requirement of the NCD would not be met/satisfied, and the request would not meet criteria for coverage. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system. 
 
You asked the Plan to pre-approve a Volara system. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 Volara system. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Volara device is not medically 
necessary. The Volara device has 3 components: Airway oscillation, positive end expiratory pressure, and 
nebulization. The device has not been shown in high-quality studies to be beneficial in the treatment of 
bronchiectasis, or to be superior to other airway clearance methods, such as the Aerobika. Nebulization would 
duplicate services already provided. Positive end expiratory pressure is unlikely to be of benefit. 
 
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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasal implants. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of nasal implants is considered 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has nasal obstruction. There is insufficient 
literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nasal implants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code G93.41 
rendered from March 11, 2022, to March 14, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration. The Plan denied your request. The Plan says the 
removal of diagnosis code G93.41 is upheld. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code G93.41. 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 pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the enrollee was evaluated and having had a witnessed seizure. The seizure was 
accompanied by a post-ictal period. There is no evidence that the enrollee had any separate issue of 
metabolically-induced altered mental status. As such, the diagnosis of G93.41 was not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code G93.41 rendered from March 11, 2022, to March 14, 
2022.