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

 
We decided that the Plan does not have to pre-approve a Koya Dayspring (non-pneumatic) Active Compression 
Garment System (K1024, K1025). 
 
You asked the Plan to pre-approve a non-pneumatic compression device. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the current peer-reviewed 
medical literature does not document equivalence or superiority of the requested non-pneumatic compression 
device over standard pneumatic compression treatment for lymphedema. 
 
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 non-pneumatic compression device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not support the medical necessity of the 
specific device in question. The enrollee has right upper extremity edema that did not respond to intravenous 
stenting nor to clavicular and mass resection. The enrollees surgeon recommended a compression sleeve and 
pump. There are no unique features of the enrollee's condition that would necessitate a particular brand or style 
of pump. There is no documentation that the enrollee has failed compression or other modalities that are 
available from the health plan. Therefore, unable to overturn the health plan determination. 
 
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 non-pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Koya Dayspring (non-pneumatic) Active Compression Garment 
System (K1024, K1025).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services rendered from March 24, 2023, to April 
18, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 24, 2023. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services rendered from March 24, 
2023, to April 18, 2023.
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 for the denial of 
inpatient rehabilitation. You say you would like to admit to the IRF for therapy and medical management. The 
Plan denied your request. The Plan says the service requested is not supported based on the records received.  
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 69990 and 63048 billed for date of service 
March 23, 2023.  
 
You asked the Plan to pay for procedure codes 69990 and 63048. The Plan denied your request. The Plan says 
the claim is not payable as billed. 
 
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, we have confirmed that code 69990 
is a column II code to column I code 63042 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. 
 
We have also confirmed that code 63048 is an add-on code and has not been billed with an appropriate primary 
procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 69990 and 63048 billed for date of service 
March 23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Corplex. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records show that the enrollee's wound 
has failed to heal with first-line medical treatments. The Corplex is requested to avoid a surgical procedure. 
The Corplex is reasonable and medically necessary based on the submitted documentation. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Corplex.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says there is no clinical evidence to support the medical 
necessity of this examination. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the member has previously been treated with outpatient therapies and 
should be independent with a home exercise program.  There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
members medical condition and therefore are not medically 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended polysomnography (95810). 
 
You asked the Plan to pre-approve an attended polysomnography. The Plan denied your request. The Plan says 
the clinical information does not show that the guidelines have been met. 
 
The Plan follows Medicare rules. Medicare rules say that prior to sleep testing, the patient has a face-to-face 
clinical evaluation by the treating physician to assess the patient for OSA which must include, at a minimum, 
the criteria listed in the Medicare rules section of this letter. 
 
 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 an attended polysomnography. Our 
reviewer says that an attended diagnostic polysomnogram is not medically necessary. Our physician reviewer 
found this enrollee has excessive daytime sleepiness and an elevated Epworth score of 12. However, our 
reviewer found that there is no complete sleep history, detailed upper airway examination, or neck 
circumference. A complete sleep history is necessary in order to determine the need for, and the appropriate 
type of, sleep study. Our physician reviewer also found that there is no justification of need for an attended 
polysomnogram rather than a home-based study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended polysomnography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an attended polysomnography (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Alpha Stim M device (E1399). 
 
You asked the Plan to pre-approve an Alpha Stim M device. You say that you are requesting this item because 
of your pain management. The Plan denied your request. The Plan says there is not enough peer-reviewed data 
on the safety and effectiveness of the requested device to show this meets the standards of good medical 
practice. Therefore, this is not considered 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 an Alpha Stim M device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have chronic low back pain. You say that you are not a candidate for surgery. 
There is no documentation of transcutaneous electrical nerve stimulation (TENS), or other non-invasive 
methods being used. This device is considered experimental/ investigational. therefore, the request is deemed 
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 an Alpha Stim M device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Alpha Stim M device (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is too complex for skilled 
nursing care as this venue, under the circumstances, poses a significant risk for readmission. The Plan denied 
your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require 
transfer to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving the appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the two-level cervical disc arthroplasty and one-level 
fusion. 
 
You asked the Plan to pre-approve the surgical services. You say that this surgery was approved to be 
performed by another doctor. You say that that doctor's approach would result in the loss of your neck mobility 
which you did not want due to being an active tennis player. You also say that this why you sought the surgery 
from another doctor who said they could preserve your neck movement. The Plan denied your request. The 
Plan says there are not enough studies on two-level cervical disc arthroplasty along with one level fusion 
(hybrid techniques) to show it is safe and effective. 
 
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 surgical services. Our reviewer says that the requested surgical services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. Moreover, there is limited published, 
large-scale, long-term peer-reviewed literature that shows Cervical Hybrid artificial disc replacement (ADR) 
and anterior cervical discectomy and fusion (ACDF) procedures to be an effective and/or safe treatment for the 
noted pathology. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the reviewer found that the requested two-level 
cervical disc arthroplasty (C4-5 and C6-7) and a one-level fusion (C5-6) is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the two-level cervical disc arthroplasty and one-level fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (15002, 15003) provided on September 9, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for out-of-network surgical services. You say that these services were medically 
necessary and were reported appropriately. The Plan denied your request. The Plan says out-of-network care is 
only covered in certain limited circumstances, which have not been met in this case. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for surgical services (15002, 15003) provided on 
September 9, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital treatment from August 4, 
2023 - forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital treatment. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital treatment. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon 
review of the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of August 4, 2023 forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. He was being cooperative and compliant while not 
showing any acute threats to safety as he awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient psychiatric hospital treatment from August 4, 2023 
- forward.
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 services are medically necessary, and you have 
already failed at a lower level of care. The Plan denied your request. The Plan says you do not meet the criteria 
for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable.  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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 00500, 36620 and 76937 billed for date of 
service February 13, 2023. 
 
You asked the Plan to pay for procedure codes 00500, 36620 and 76937. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
services billed. 
 
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 00500 is: Anesthesia for all procedures on esophagus. 
The definition of code 36620 is: Arterial catheterization or cannulation for sampling, monitoring or transfusion 
(separate procedure); percutaneous. The definition of code 76937 is: Ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 
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 procedure codes 00500, 36620 and 76937. Our reviewer says 
that procedure codes 00500 and 36620 do not meet criteria for payment. Our reviewer found that the medical 
record does not include an anesthesia report, and therefore procedure code 00500 cannot be verified. The 
operative report also does not include documentation of arterial catheterization or cannulation, and therefore 
procedure code 36620 cannot be verified. Code 36620 pertains to a procedure in which the provider inserts a 
catheter percutaneously (through the skin) into an artery and uses this catheter for the purpose of sampling, 
transfusion, or continuous realtime blood pressure and heart rate monitoring. This procedure was not found in 
operative report. The operative report also does not include documentation of ultrasound guidance for vascular 
access. The provider uses ultrasound to help guide procedures requiring vascular access including central 
venous, peripheral venous, or arterial access procedures. This procedure was not found in operative report, and 
therefore procedure code 76937 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 00500, 36620 and 76937 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 00500, 36620 and 76937 billed for date of 
service February 13, 2023.