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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
Segmental pneumatic appliance for use with pneumatic compressor, chest (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and a garment. You say that you have 
swelling in your face and chest. You had cancer surgery, and you need these devices. The Plan denied your 
request. The Plan says the records do not show that you have lymphedema that extends to the chest, trunk, and 
or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that you had at least four weeks 
of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and 
supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.  
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
a Segmental pneumatic appliance for use with pneumatic compressor, chest (E0657).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of anesthetic agent or steroid, genicular 
nerve branches (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that you are requesting reconsideration 
based on medical necessity. The Plan denied your request. The Plan says the service is 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 a genicular nerve block. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy at this time. It is the subject of ongoing clinical trials. 
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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of anesthetic agent or steroid, genicular nerve branches (64454).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0300, Q5001 G0162) provided on 
July 20, 2022, to August 18, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial and request 
reconsideration. 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 April 21, 2022. The NOA was not received by the Plan until November 14, 
2022. 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 (G0300, 
Q5001 G0162) provided on July 20, 2022, to August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches (64624). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the request is medically necessary. 
The Plan denied your request. The Plan says the request is not reasonable and 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 a genicular nerve block. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy and there are ongoing clinical trials. 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction by neurolytic agent, genicular nerve branches (64624).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home visit from a pain management doctor. 
 You asked the Plan to pre-approve home health services. You say that you are not able to leave your house due 
to your condition. The Plan denied your request. The Plan says the documentation does not show that you were 
referred by their doctor. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that it is not 
clear that you are homebound. You have been able to attend primary care physician (PCP) appointments. You 
make use of mobility equipment. You could use telemedicine services. The records do not show that a home 
pain management visit is medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home visit from a pain management doctor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) (93010) billed for date of 
service May 10, 2023. 
 You asked the Plan to pay for the ECG. You say that medical records submitted support code 93010-76 and 
should be paid. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment 
for code 93312. 
 
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 93010 
is a column II code to column I code 93312. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the electrocardiogram (ECG) (93010) billed for date of service 
May 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650, 99152). 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless certain 
conditions have been 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 a spinal cord stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the lack of psychological 
clearance means that she does not meet the NCD and LCD criteria. Therefore, at this time, 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator (63650, 99152).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac 
contractility modulation system, including contractility evaluation when performed (0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart modulation system. You say that the enrollee needs the 
requested procedure to improve his quality of life. The Plan denied your request. The Plan says a review of the 
current medical literature indicates that this service is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Optimizer Smart modulation system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found an exhaustive review of the current medical literature pertaining to the 
cardiac contractility modulation (CCM) system confirms multiple observational studies suggesting clinical 
benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along 
with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in 
quality-of-life scores and objective functional capacity. While the clinical studies led to Food and Drug 
Administration (FDA) approval in 2019, CCM remains the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the 
current time, the reviewer would not consider the CCM system to be medically necessary in this enrollee. 
 
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 Optimizer Smart modulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac contractility 
modulation system, including contractility evaluation when performed (0408T).
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 meets Medicare criteria and will benefit 
from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, in an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. The enrollee's skilled therapy needs could be met in a lower 
level of care such as a skilled nursing facility.  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs these services to return to their 
prior level of function. The Plan denied your request. The Plan says the enrollee does 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 the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 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 
inpatient rehabilitation facility.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 30, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the medical records 
submitted don't include an order that specifically lists what test(s) are to be performed in the custom panel. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order for the specific testing provided in this case. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on March 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided January 25, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
services was not filed until April 10, 2023. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
ambulance services provided January 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar laminectomy and L4-L5 transforaminal 
interbody lumbar fusion (TLIF) posterior instrumented fusion. 
 
You asked the Plan to pre-approve a lumbar laminectomy and instrumented fusion. You say that you are 
appealing the denial. The Plan denied your request. The Plan says that the enrollee does not meet any of the 
requirements. 
 
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 lumbar laminectomy and 
instrumented fusion. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there are no imaging studies showing 
instability at any level. There is no recent magnetic resonance imaging (MRI) showing severe stenosis. 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 lumbar laminectomy and instrumented fusion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a lumbar laminectomy and L4-L5 transforaminal 
interbody lumbar fusion (TLIF) posterior instrumented fusion.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zilretta (J3304). 
 
You asked the Plan to pre-approve Zilretta. You say that Zilretta is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says Zilretta is not medically necessary for re-treatment of a previously 
treated knee. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that 
treatment with Zilretta is not medically reasonable and necessary in this case. Our physician reviewer found 
that repeat use of Zilretta is off-label and not evidence-based. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Zilretta (J3304).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 93460-26, 99152, and 
93571-26. We decided that the Plan does not have to pay for the services described by procedure code(s) 
99153.  
 
You asked the Plan to pay for practitioner services provided on June 6, 2023, billed with procedure codes 
99153, 93460-26, 99152, and 93571-26. You say that the claim is billed correctly and should be paid. The Plan 
says that code 99153 is not payable in the facility setting.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 93460-26, 99152, and 
93571-26.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 93460-26, 99152, and 93571-
26.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99153. 
 
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE 
only code and that PE are not payable to the physician for services provided in the facility setting.  
 
We looked at the file, and Medicare rules. We find that payment for CPT code 99153 is not supported. 
Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility 
setting. Based on this information, we decided that Medicare rules for coverage of the services described by 
procedure code(s) 99153 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 99153. 
 
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.