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

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
doctor for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied your request. The 
Plan says The MyoPro Motion G (L8702) this is considered experimental and investigational due to 
insufficient evidence of safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral endovenous ablation therapy of incompetent 
vein (36478). 
 
You asked the Plan to pre-approve the bilateral endovenous ablation therapy. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says there is no documentation of a response 
to conservative medical treatments. The Plan also says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation therapy may be considered 
medically necessary for varicose veins when certain criteria 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 pre-approve the bilateral endovenous ablation 
therapy. Our reviewer says that the requested bilateral endovenous ablation therapy is not medically necessary. 
Our physician reviewer found the provided documentation indicates that the enrollee presented with sudden 
onset of pain of only two weeks duration. The reviewer found that the enrollee required an x-ray and was 
diagnosed with an ankle sprain. It is documented that the enrollee was previously using compression 
stockings. Based on the medical records provided, it is not clear that the enrollee has significant symptoms due 
to the varicose veins as the pain was recent, sudden, and they were diagnosed with an ankle sprain. Therefore, 
the reviewer found that the requested bilateral endovenous ablation therapy 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 bilateral endovenous ablation therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bilateral endovenous ablation therapy of incompetent vein 
(36478).
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 cannot walk or be safely discharge home. The 
Plan denied your request. The Plan says the request is 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Favorable

 
We decided that the Plan has to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), 
with imaging guidance (64635, 64636). 
 
You asked the Plan to pre-approve the radiofrequency ablation (RFA). You say that the enrollee had less pain 
when doing activities that would normally trigger their pain. You also say that the enrollee had an increase of 
functional ability. You also say that the requested RFA is medically necessary. The Plan denied your request. 
The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is medically necessary after 
the enrollee has had two medial branch blocks, each providing 80% relief of primary pain. 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the requested radiofrequency ablation (RFA) is medically necessary. Our physician reviewer 
found the provided records indicate that the enrollee achieved at some point 80% in each set of medial branch 
blocks (MBBs). Therefore, the reviewer found that the requested RFA is 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 radiofrequency ablation (RFA) have been met. Therefore, we decided that 
the Plan has to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (64635, 64636).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Orthovisc or Supartz FX. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the preferred drugs, Orthovisc or Supartz FX. The reviewer found that there is 
no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for 
the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular testing described by code 95937 billed on 
May 17, 2023. 
 
You asked the Plan to pay for 95937. You say that 95937 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 95937 is denied because it is not supported in the 
documentation. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any one method. 
 
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 95937. Our reviewer says that 95937 is not 
supported in the documentation. Our reviewer found records indicate train of four testing was performed on 
May 17, 2023, as part of a lumbar spine surgery. Train of four testing is a technique to measure the level of 
neuromuscular blockade when neuromuscular blocking agents are utilized. CPT code 95937 represents 
neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method. The 
documented train of four testing does not meet criteria for coverage under CPT 95937. There is no indication 
that the train of four testing was separate and distinct from the intraoperative neurophysiologic monitoring 
(95941).  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95937 have not been met. Therefore, we decided that the Plan does not have to 
pay for the neuromuscular testing described by code 95937 billed on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715), and administration (90471) provided on March 27, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that you were unaware that this could have been 
covered if you had received the services at a pharmacy. You also say that you feel you should not be 
responsible for this bill. The Plan denied your request. The Plan says this is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) (90715), and administration (90471) provided on March 27, 2023.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 for date of service May 18, 2023. 
 
You asked the Plan to pay for procedure code 96372. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are 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. 
 
We find that CPT code 96372 is not payable as billed. Specifically, code 96372 has a status indicator of Q1. 
Code 99285 was billed on the same claim, with the same date of service, with a revenue code of 450. This 
gives 99285 a status indicator of V (clinic or emergency department visit). Therefore, procedure code 96372, 
which has a status indicator of Q1, not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 96372 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 96372 for date of service May 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex device (22868, 22867). 
 
You asked the Plan to pre-approve a Coflex device. 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 Coflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested Coflex device is not 
medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Coflex device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex device (22868, 22867).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99233 billed for dates of service March 9, 2023, to March 13, 
2023. 
 
You asked the Plan to pay for code 99233. You say that this claim was coded correctly and should be paid as 
billed. The Plan denied your request. The Plan says that code 99233 is not supported by the medical record. 
The patient did not have any new or severe exacerbations of symptoms or diseases or require any intervention 
right away that may pose a threat to life or bodily function. As a result, this claim was down-coded to 99232. 
 
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 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 code 99233. Our reviewer says that code 99233 is supported 
by the medical record. Our reviewer found the enrollee was seen and evaluated immediately after a cardiac 
procedure.  The enrollee was not adhering to post-procedure protocols and needed additional encouragement to 
do so.  Additionally, the enrollees medication schedule had been altered for the procedure and subsequent 
adjustments were made.  The medical decision making was active.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have been met. Therefore, we decided that the Plan has to pay for 
code 99233 billed for dates of service March 9, 2023, to March 13, 2023.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve SNF services. 
 
You asked the Plan pre-approve SNF services. You say that continuation of SNF services is necessary for the 
enrollee to receive the care needed to improve functionality. The Plan denied your request. The Plan says you 
have used all the SNF days that are covered under your Plan during your current benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The Plan covers 120 
days of skilled care in a SNF in each benefit period, which goes beyond Medicares coverage. 
 
The file shows that the enrollee received 120 days of SNF care during the benefit period from January 24, 
2023, to October 27, 2023. The Plan has covered 120 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 120 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have pre-approve SNF services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve cryosurgical ablation of the prostate. 
 
You asked the Plan to pre-approve the cryosurgical ablation. You say that the enrollee will not be doing 
radiation therapy. The Plan denied your request. The Plan says that the records do not show that the enrollee 
has tried and failed radiation treatment. 
 
The Plan follows Medicare rules. Medicare rules say that cryosurgery of the prostate gland is safe and 
effective, as well as medically necessary and appropriate, as primary treatment for patients with clinically 
localized prostate cancer, Stages T1-T3. 
 
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 cryosurgical ablation. Our reviewer 
says that the requested cryosurgical ablation is medically necessary. Our physician reviewer found the records 
show that the enrollee has localized prostate cancer (stage T1c) which meets the coverage criteria. Therefore, 
the reviewer found that the requested cryosurgical ablation service is 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 cryosurgical ablation have been met. Therefore, we decided that the Plan 
has to pre-approve cryosurgical ablation of the prostate.  
 
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 laboratory services (82306, 82607) provided May 25, 
2023. 
 You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says screening services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the laboratory services (82306, 82607) provided May 25, 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 the enrollee needs this level of care. The Plan denied 
your request. The Plan says the enrollee's condition does not meet the criteria for an IRF admission.  
 
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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 12, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 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 June 12, 2023.