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

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861), a tilt and recline power seating system (E1007) with a power elevating leg rest (E1012), and 
an expandable controller (E2310, E2311, E2377, E2313). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options, a tilt and recline 
power seating system with a power elevating leg rest, and an expandable controller. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says the enrollee does not require 
multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with Multiple 
Power Options (K0861) is covered if the beneficiary's mobility limitation is due to a neurological condition, 
myopathy, or congenital skeletal deformity; and either the beneficiary meets coverage criteria for a power tilt 
and recline seating system and the system is being used on the wheelchair or the beneficiary uses a ventilator 
which is mounted on the wheelchair. If the PWC base is not covered, then related accessories will be denied. 
 
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 group 3 power wheelchair with 
multiple power options, a tilt and recline power seating system with a power elevating leg rest, and an 
expandable controller. Our reviewer says that the requirements for coverage have not been met. Our physician 
reviewer found there is inadequate clinical documentation regarding why the enrollee requires power tilt and 
recline and cannot adequately perform pressure relief. There is no history of skin breakdown. There is no 
significant lower extremity spasticity or edema that would necessitate a power elevating foot platform. 
 
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 group 3 power wheelchair with multiple power options, a tilt and recline 
power seating system with a power elevating leg rest, and an expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options (K0861), a tilt and recline power seating system (E1007) with a power elevating leg rest 
(E1012), and an expandable controller (E2310, E2311, E2377, E2313).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim System procedure. 
 
You asked the Plan to pre-approve a Barostim System procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Barostim System procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. 
 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 Barostim System procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Barostim System procedure.
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 you are asking for reconsideration of the denied 
services. The Plan denied your request. The Plan says these services are not medically necessary for the 
enrollee.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no 
complex nursing or rehabilitation needs.  The enrollee does not require treatment by multiple therapies. While 
the medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy. 
 
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 ultrasound-guided radiation therapy is 
approved by the Food and Drug Administration (FDA) for use with ultrasound; however, billing for daily 
simple simulations and/or image-guided radiation therapy (IGRT) has not been established by published data 
and is not supported by consensus guidelines. The use of daily IGRT is not the standard of care and is not 
reasonable or medically necessary for the enrollee, based on the submitted records.  
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 ultrasound-guided radiation therapy.
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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. There is reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF, but the services 
required can be provided at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 27, 2023, to May 28, 
2023, billed with evaluation and management (EM) code 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99233 is subsequent 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, 50 minutes must be met or exceeded. 
 We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that at least 50 
minutes were spent. 
 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 27, 2023, to May 28, 2023, billed with 
evaluation and management (EM) code 99233.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac contractility modulation (CCM) therapy 
(0408T). 
 
You asked the Plan to pre-approve CCM therapy. You say that the requested treatment is medically necessary. 
The Plan denied your request. The Plan says the data in published medical literature is inadequate to permit 
scientific conclusions on long-term and net health outcomes. 
 
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 CCM therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CCM delivers non-excitatory electrical signals to the right side of the intraventricular septum 
during the absolute refractory period of the ventricular contraction and does not trigger a new action 
potential. The literature has determined that cardiac contractility modulation (CCM) therapy, administered by 
Impulse Dynamics' Optimizer system, is experimental and investigational because the effectiveness of this 
approach has not been established. The review has determined that the items/services at issue in this case are 
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 CCM therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac contractility modulation (CCM) therapy (0408T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 30, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider type is 
not payable for these services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the services provided on May 30, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 19, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that F06.4 has an Excludes1 note in relation to F03.90. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on August 10, 
2023. 
 
You asked the Plan to pay for the dental services. You say that it had been over 180 days since your previous 
exam. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 2, 2023, and March 13, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120) provided on August 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision lumbar spinal fusion. 
 
You asked the Plan to pre-approve revision lumbar spinal fusion. You say that the procedure will likely benefit 
the enrollee, as other methods have not been helpful. The Plan denied your request. The Plan says that the 
request does not meet medical requirements. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar spinal fusion may be covered under certain 
circumstances. 
 
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 revision lumbar spinal fusion. Our 
reviewer says that in this case, the requested revision lumbar spinal fusion is not medically reasonable or 
necessary. Our physician reviewer found that detailed documentation is not evident on the provided diagnostic 
imaging studies of the lumbar spine corroborating lumbar pseudoarthrosis or any hardware failure. There is no 
clear documentation of adjacent level pathology that requires surgical intervention. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revision lumbar spinal fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revision lumbar spinal fusion.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve physician attendance and supervision of hyperbaric oxygen 
therapy (99183) and hyperbaric oxygen (HBO) under pressure, full body chamber, per 30-minute interval 
(G0277). 
 
You asked the Plan to pre-approve HBO therapy. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says that the records do not show that the enrollee 
has had correction of vascular disease. The enrollee has not had surgical debridement or debridement of the 
exposed bone. 
 
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 HBO therapy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee underwent a 5th ray amputation on August 20, 2023. There was a subsequent 
nonhealing ulceration. The enrollee was not a candidate for revascularization because of stage IV chronic 
kidney disease. The enrollee underwent a 6-week course of antibiotics, managed by an infectious disease 
consultant. Diabetic control and nutritional issues were addressed. The wound was determined to be Wagner 
stage III. Measurements beginning October 6, 2023, and ending November 7, 2023, showed no significant 
wound healing. Medicare criteria are met for hyperbaric oxygen therapy. The denial is reversed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have been met. Therefore, we decided that the Plan has to pre-
approve physician attendance and supervision of hyperbaric oxygen therapy (99183) and hyperbaric oxygen 
(HBO) under pressure, full body chamber, per 30-minute interval (G0277).   
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 lab panel provided on May 22, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says a panel cannot be 
unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
unit of one code as required by LCA A58761. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 26, 2023 to July 27, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 26, 2023 to July 27, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482). 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are 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 pay for the definitive UDT for 15-21 drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that there is no 
documentation of early renewals, abuse, or diversion. There is no qualitative screen present. There was no 
indication to do this testing. The request was not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the definitive UDT for 15-21 drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482).