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

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee needs to undergo this 
procedure. The Plan denied your request. The Plan says there is no documentation of at least 50% improvement 
in pain or function for at least 6 months from the previous injection. 
 The Plan follows Medicare rules. Medicare rules state that if an extended period of time, such as two years or 
more, has passed since the last radiofrequency ablation (RFA) then diagnostic facet joint procedures must be 
repeated. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet criteria for these injections. Our physician reviewer found the diagnostic blocks 
have to be repeated because it has been more than 2 years since the previous radiofrequency ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve paravertebral facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that electronic brachytherapy is 
medically necessary to treat the patient's skin cancer. This is the best option for this patient because 
brachytherapy delivers a higher dose of radiation directly to the tumor while sparing healthy tissue nearby. The 
Plan denied your request. The Plan says current medical literature does not support the use of electronic 
brachytherapy for the patient's condition to be 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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The most recent National Comprehensive Cancer Network guidelines for basal cell and squamous cell skin cancers explicitly state There are insufficient long-term efficacy and safety data to 
support routine use of electronic surface brachytherapy.  Earlier versions (1.2016 and before) did not 
specifically address electronic brachytherapy (EBT) or superficial radiation (SRT), and only mentioned 
electron and orthovoltage beams as means to deliver radiation.  Generally, electron therapy or orthovoltage 
therapy are considered standard means to deliver radiation. For this case, there are no compelling reasons 
offered for why electronic brachytherapy would be needed over more standard approaches of radiation 
delivery. Electronic brachytherapy would not be the standard treatment for this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99232 for date of service September 14, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that evaluation and management codes are not covered for this 
specialty or provider type. 
 
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 states that evaluation and management codes are not covered for this 
specialty or provider type. No explanation or Medicare rules were provided to show why these services cannot 
be billed by the billing provider. No other denial rationale was provided. The Plan did not substantiate their 
denial. Therefore, we decided that the Plan has to pay for procedure code 99232 for date of service September 
14, 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 the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says CardioMEMS should only be approved for enrollees in a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term outcomes to 
establish the value of CardioMEMS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that IRF services are 
not medically necessary. 
 
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 complexity of the enrollee's nursing medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted to the 
hospital on May 22, 2203, after falling and sustaining and C5/6 extension injury with spinal cord injury, rib 
fractures on the right from ribs 7-10, and a right sided humerus fracture. Our reviewer found that the enrollee 
required a C3-T1 fusion on May 23, 2023. The enrollee's hospital course is notable for urinary retention 
secondary to their spinal cord injury as well as hyponatremia. Our physician reviewer found that given the 
enrollee's trauma and spinal cord injury, they would benefit from the oversight of rehabilitation physician. The 
enrollee does require rehabilitation nursing, including care for neurogenic bladder. Our reviewer also found 
that the enrollee's medical and rehabilitation needs do require the intensive interdisciplinary approach provided 
on acute inpatient rehabilitation. 
 
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 
an 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering system (L5964). 
 
You asked the Plan to pre-approve a protective outer surface covering system. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical 
environment. Protective outer surface coverings are different from the covering that is already reimbursed as 
part of L5704, L5705, L5706, and L5707. 
 
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 protective outer surface covering 
system. Our reviewer says that the enrollee does not need this item. Our physician reviewer found the 
documentation does not support that the member requires a specialized outer coating for the replacement 
prosthesis or that they are exposed to an unusually harsh environment. 
 
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 protective outer surface covering systems have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a protective outer surface covering system (L5964).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on November 23, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the supplies provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service January 20, 
2023.  
 
You asked the Plan to pay for procedure code 99458. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99458 is 3. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 enrollee has chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD). Provided records document that the 
home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with 
auto-EPAP (AE) which could be provided by a BiPAP device with average volume assured pressure support 
(AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. Medicare does not cover a home ventilator for this purpose. 
 
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 home ventilator.
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 requires intensive rehabilitation before 
returning home. The Plan denied your request. The Plan says the enrollee's needs can be met at an alternate 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the records do not show the enrollee has a complex rehabilitation need 
necessitating evaluation by a rehab doctor 3 times per week or that they can tolerate 3 hours of therapies per 
day given their limitations from pain and fatigue. They can be reasonably expected to improve at a lower level 
of care with good success. The services they need can be provided safely in other settings, for example, a 
skilled nursing facility. 
 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytogenetic studies (88271 and 88275) provided on 
December 16, 2022. 
 
You asked the Plan to pay for cytogenetic studies. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services were not provided for a covered indication and therefore 
are denied. 
 The Plan must follow Medicare rules. Medicare rules say that cytogenetic studies are covered for certain 
conditions.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of cytogenetic studies have not been met. Specifically, the services in question were not provided for 
one of the covered conditions. Therefore, we decided that the Plan does not have to pay for cytogenetic studies 
(88271 and 88275) provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code cannot be verified. 
 
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 care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. 
 We find that CPT code 99223 is not supported in the medical record. The records show that the enrollee 
received a consult for pacemaker placement. The records do not include a comprehensive history, exam, or 
decision making of high complexity. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 99223 billed for date of service September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 13, 2021, to 
April 16, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of diagnosis code G93.41. 
 
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 submitted records do not support the billing of diagnosis code G93.41. Our physician 
reviewer found the enrollee presented to the hospital for evaluation of intractable diarrhea for the past two 
weeks. Initial infectious workup was unrevealing, and the enrollee underwent evaluation by gastroenterology 
with upper endoscopy and colonoscopy. Discharge diagnoses included rule out for microscopic colitis with 
biopsies pending, LA grade C reflux esophagitis, diverticulosis, and acute metabolic encephalopathy. The 
physical examinations in the medical record do not demonstrate a significant change or improvement in mental 
status during the admission; therefore, diagnosis code G93.41 is 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 provided on April 13, 2021, to April 16, 2021, at the Diagnosis Related Group 
(DRG) originally billed.