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

 
We decided that the Plan does not have to pre-approve a power operated scooter (K0800), and battery (E2365). 
 
You asked the Plan to pre-approve a power scooter and battery. You say that you have hip pain, chronic back 
pain, and her mobility and access around is becoming a little more limited. You say that you have arthritis in 
your hip and can only walk 10 feet before your hips start hurting. You also say that the pain goes straight 
across your back and you have to sit down. The Plan denied your request. The Plan says there is no 
documentation indicating you cannot self-propel a manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a power operated vehicle (POV) may be covered if 
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 a power scooter and battery. Our 
reviewer says that the requested power scooter is not medically necessary. Our physician reviewer found the 
documentation indicates the enrollee has a mobility limitation that impairs the ability to complete some 
mobility related activities of daily living (MRADLs). The documentation does not clearly reveal that the 
mobility deficit cannot be resolved be a cane or walker or manual wheelchair. There is no detailed upper 
extremity musculoskeletal or neuromuscular examination indicating why these devices would not be able to be 
used. The documentation is not clear that the home is appropriate for a power operated scooter as there are no 
objective measurements of the home indicating that the enrollee's home provides adequate access between 
rooms, maneuvering space, and surfaces for use of the power scooter. Without evidence that the power 
operated vehicle will provide adequate space in the home it is not clear that the requested wheelchair will 
significantly improve participation in MRADLs in the home. Therefore, the reviewer found that the requested 
power scooter and battery 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 a power scooter and battery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated scooter (K0800), and battery (E2365).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of peripheral nerve 
stimulator (PNS) (64555 x 2). 
 
You asked the Plan to pre-approve implanted PNS. You say that the enrollee has trialed and not sustained long 
term benefit from non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and muscle relaxers. You say that 
the enrollee's pain limits their activities of daily living, and the ability to work, fulfill family role and fulfill 
social role. You also say this is medically necessary for the enrollee. The Plan denied your request. The Plan 
says the requested treatment 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 implanted PNS. Our reviewer says that 
the requested implanted PNS device is not considered medically reasonable and necessary in this case. Our physician reviewer found implantable peripheral nerve stimulators for chronic pain are still being studied to see 
if this treatment is reasonable and necessary. Overall, there is lack of evidence to support PNS over traditional 
treatment of chronic low back pain. There is a lack of literature evaluating long-term efficacy and adverse 
events associated with implantable PNS devices. Long-term data are especially important for these 
technologies due to the invasive (and in some cases, permanent) nature of theses device. Potential long-term 
complications include those seen with spinal cord stimulators, including lead migration, lead fracture, seroma, 
infection, and hematoma. Therefore, the reviewer found that the implanted PNS 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 implanted PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous implantation of peripheral nerve stimulator (PNS) (64555 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that sacroiliac joint 
radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says sacroiliac joint 
radiofrequency ablation does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that SIJ denervation (also called Radiofrequency Ablation 
or RFA) is not considered reasonable and 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 sacroiliac joint radiofrequency ablation. 
Our reviewer says that the requested sacroiliac joint radiofrequency ablation is not considered medically 
necessary. Our physician reviewer found that sacroiliac joint radiofrequency ablation is still considered an 
experimental procedure due to the wide variation in efficacy reported in the literature. 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 sacroiliac joint radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
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 you are requesting an expedited 
reconsideration stating the enrollee clearly exceeds the criteria for an appropriate LTACH admission. The Plan 
denied your request. The Plan says the enrollee does not meet the guidelines for care in 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 the enrollee is receiving an appropriate level of care in the present setting, and 
the Plan has not stated that continued care in the short-term acute hospital will not be covered. The enrollee 
does not appear to be stable for transfer due to an ongoing ileus as well as ongoing agitation, altered mental 
status and delirium requiring restraints. Continued care in the short-term acute hospital is appropriate until the 
enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute 
rehabilitation facility or 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 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 ProACT implant procedure. 
 
You asked the Plan to pre-approve ProACT implant procedure. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 ProACT implant procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has prostate cancer treated with robotic radical prostatectomy 
in 2018. The enrollee has been impotent and incontinent since then. The enrollee had prostate-specific antigen (PSA) recurrent prostate cancer and received salvage radiation treatments in 2020. Pelvic floor muscle therapy 
and Ditropan have not helped the incontinence. The ProACT adjustable continence therapy device is 
experimental/investigational. It has not been scientifically demonstrated to be as safe and effective as 
conventional treatment. The ProACT device does not appear to be an ideal device for durable continence and 
enrollees satisfaction. Additional studies preferably controlled and ideally, random controlled trials are 
needed. The evidence is insufficient to determine the effects of the technology on health outcomes. Therefore, 
the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ProACT implant procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ProACT implant procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that the enrollee needs this medication. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred drug, Venofer. 
 
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 Feraheme. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
support that the enrollee has tried and failed the preferred drug. The reviewer also found there is no 
documentation provided indicating that the plans required drug 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81479, 0029U, 81240, 81241, 81306, 81335 
and 81401 billed for date of service October 12, 2021. 
 You asked the Plan to pay for procedure codes 81479, 0029U, 81240, 81241, 81306, 81335 and 81401. You 
say that these services were reported correctly. The Plan denied your request. The Plan says payment for codes 
0029U, 81240, 81241, 81306, 81335 and 81401 is bundled into payment for code 0078U. Code 81479 is not 
supported as the panel provided has already been accurately reported with code 0078U. 
 
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 codes 
0029U, 81240, 81241, 81306, 81335 and 81401 are all column II codes to column I code 0078U. These 
services have not been billed with an appropriate modifier to bypass the edit. In addition, 81479 is an unlisted 
code which is only to be used when the services provided cannot be described by a more accurate code. Code 
0078U describes the panel provided and has already been paid by the Plan. 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 81479, 0029U, 81240, 81241, 81306, 81335 and 81401 billed for date of service October 12, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation services billed with code 64625 
for date of service October 18, 2022. 
 
You asked the Plan to pay for the radiofrequency ablation services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation for denervation whether 
performed using traditional, cooled, or pulsed radiofrequency is considered investigational and therefore, not 
medically necessary. 
 We looked at the file and Medicare rules. Services identified with code 64625 are specifically not covered. 
Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation services 
have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation 
services billed with code 64625 for date of service October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that the enrollee's skin graft is failing. You also say 
that this treatment is medically necessary. The Plan denied your request. The Plan says the requested treatment 
is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for HBO therapy will be limited to that 
which is administered in a chamber (including the one-man unit) and is limited to certain conditions. 
 
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 HBO therapy is not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee has squamous cell carcinoma of the tongue status post-surgery and skin 
graft to the jaw which was reported to have failed. The documentation does not indicate that surgery is planned. 
There is no evidence of infection having failed primary treatments. The provided documentation does not 
describe a compromised skin graft, but rather a failed graft which would not respond to HBO therapy. 
Therefore, the reviewer found that the requested HBO 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64636, 64635). 
 
You asked the Plan to pre-approve RFA. 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 an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 RFA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the LCD criteria is at least 6 months of 
pain relief to be considered a successful intervention. This was not achieved and 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) (64636, 64635).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88305 billed for date of service July 13, 2022. 
 
You asked the Plan to pay for procedure code 88305. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this claim is denied. 
 
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 has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for procedure code 88305 billed for date of 
service July 13, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 07, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high dose rate electronic brachytherapy, skin surface 
application, per fraction, includes basic dosimetry, when performed (0394T), therapeutic radiology simulation-
aided field setting; simple (77280), therapeutic radiology simulation-aided field setting; complex (77290) and 
an office visit (99213). 
 
You asked the Plan to pre-approve an office visit and brachytherapy. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says there are insufficient long-term 
efficacy and safety data to support the routine uses of electronic surface brachytherapy. 
 
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 office visit and brachytherapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a diagnosis of squamous cell carcinoma of skin of other 
parts of the face with superficial invasion. A biopsy was performed. NCCN Guidelines Version 1.2023 
(Squamous Cell Skin Cancer) states, "There are insufficient long-term efficacy and safety data to support the 
routine use of electronic surface brachytherapy." There is no evidence comparing electronic surface 
brachytherapy with other treatment regimens. 
 
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 office visit and brachytherapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a high dose rate electronic brachytherapy, skin surface application, per 
fraction, includes basic dosimetry, when performed (0394T), therapeutic radiology simulation-aided field 
setting; simple (77280), therapeutic radiology simulation-aided field setting; complex (77290) and an office 
visit (99213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (0240U) provided on December 19, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test is supported in the medical record. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (0240U) 
provided on December 19, 2022.