Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches. You say that the 
enrollee is in excruciating pain and you feel it is necessary for the enrollee to have for a better sense of health. 
The Plan denied your request. The Plan says genicular radiofrequency ablation is considered experimental 
and/or unproven. 
 
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 destruction by neurolytic agent, 
genicular nerve branches. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this procedure is considered 
experimental/investigational. 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 destruction by neurolytic agent, genicular nerve branches have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular 
nerve branches including imaging guidance (64624).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64447 billed for date of service September 19, 2022. 
 
You asked the Plan to pay for the billed code. You say that the service was billed according to the guidelines. 
The Plan denied your request. The Plan says that the code is not separately reportable. 
 
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 64447 is supported in the medical record. The file shows that code 64447 was billed 
with general anesthesia code 01407. The Plan has not shown that the adequacy of anesthesia code 01407 was 
dependent on code 64447. Code 64447 was billed with the 59 modifier as required. The injection may be 
administered preoperatively, intraoperatively, or postoperatively.  Based on this information, we decided that 
Medicare rules for coverage of the billed code have been met. Therefore, we decided that the Plan has to pay 
for procedure code 64447 billed for date of service September 19, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service July 24, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation justifies the services. The 
Plan denied your request. The Plan says the testing does not meet the criteria. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 88374 was billed with diagnosis code R13.10, defined as unspecified dysphagia. This 
diagnosis is not among those for which cytogenetic testing is covered. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88374 billed for date of service July 24, 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 have no kidneys and has a wound vac. You say 
the IRF will help you regain your independence. The Plan denied your request. The Plan says the IRF care is 
not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility.  
 
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 were admitted for nephrectomy and hernia repair. Your medical problems are 
stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
LTACH services due to current medical management necessity and hospitalization. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 has ongoing acute medical issues and still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections 
 You asked the Plan to pre-approve the injections. You say that the enrollee previously tried physical therapy 
with no relief. You say that the enrollee's pain is exacerbated with prolonged sitting and standing. The Plan 
denied your request. The Plan says facet joint injections 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 the injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that there is no imaging that 
supports the diagnosis and there are not radicular symptoms present. Therefore, the request does not meet the 
LCD coverage criteria and is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections
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 LTACH services. You say that the enrollee requires LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for an LTACH admission. 
 
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 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 record indicates that this enrollee still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH 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 will benefit from acute inpatient rehab 
that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says an IRF 
admission 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 the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles (K0108x2), power footplate extension 
transfer assist (K0108), and miscellaneous, durable medical equipment (DME) (E1399). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that Medicare has reviewed, approved and 
found it medically necessary and covered. You also say that the Plan should follow Medicare's decision. The 
Plan denied your request. The Plan says these items do not serve a medical need and cannot be covered. 
 
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 wheelchair accessories. 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 tetraplegia and relies on a power wheelchair. Medical necessity for 
the requested items is not provided in the records. Per Social Security Administration (SSA) 1862 (a) 1 (A), 
push handles are not medically necessary nor is a power foot extension. The DME does not meet DME criteria 
for item which withstands repeated use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve push handles (K0108x2), power footplate extension transfer assist (K0108), and 
miscellaneous, durable medical equipment (DME) (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are medically 
necessary. The Plan denied your request. The Plan says due to the enrollee's age they do not meet the criteria 
for the requested CT scan. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is 80 years old. Therefore, we decided 
that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer 
screening.
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's chance to return home and maintain 
living at home will be significantly reduced if their opportunity to participate in an acute rehabilitation program 
is denied. The Plan denied your request. The Plan says an IRF admission is not medically necessary, but skilled 
therapies as an outpatient or at a skilled nursing facility (SNF) may be approved upon request.  
 
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 is medically stable and does not need physician supervision three times a 
week in an IRF. There is no medical complexity noted. There are no acute rehabilitation nursing needs 
documented. At the current functional level, the enrollee needs routine physical and occupational therapy. The 
enrollee does not need intensive therapies consisting of at least three hours of therapy per day at least five days 
per week with multidisciplinary approach in an IRF. The documentation does not support necessity for 
admission to an IRF. The complexity of the enrollees medical, rehabilitation, and nursing needs (combined 
complexity) does not require acute hospital inpatient rehabilitation stay with an interdisciplinary approach to 
rehabilitative care. The enrollees rehabilitation needs can be safely provided in an alternate and low intensity 
setting such as in a skilled nursing facility (SNF).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental extraction (D7210) provided on September 
13, 2023. 
 
You asked the Plan to pre-approve the dental extraction. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental extraction (D7210) provided on September 13, 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 meets the criteria for an IRF admission 
and will benefit from the rehabilitation that cannot be accomplished at a lower level of care. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements 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 complexity of the enrollee's nursing, medical, and rehabilitation needs can be 
provided at a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is 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, but the services required can be provided in a 
lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that trilogy is essential therapy for the 
enrollee's chronic hypercapnic respiratory failure because of its ability to have dual prescription to assist with 
rapid respiratory decline avoiding hospitalization and deterioration of their condition. The Plan denied your 
request. The Plan says a home ventilator is not medically necessary for this patient because their needs can be 
met with an alternative device such as a BiPAP device with average volume-assured pressure support 
(AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee is 
complaint with a BiPAP and has not indication of failure. The next best step would be a BiPAP with AVAPS 
therapy. There is no indication for a home ventilator per documentation or data provided. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a joystick mounting adapter (K0108), Gatlin midline 
mount for quickie/quantum (K0108), track mounted clamp (K0108), track nut for sunrise chair (K0108), 
retractable or removable mounting hardware for joystick (E1028), and repairs or non-routine services for 
durable medical equipment other than oxygen equipment (K0739).  
You asked the Plan to pre-approve a joystick mounting adapter, Gatlin midline mount, track mounted clamp, 
track nut, retractable or removable mounting hardware, and repairs or non-routine services. The Plan denied 
your request. The Plan says the cost of the requested repairs plus previous repairs surpasses the replacement 
cost of the wheelchair as currently configured. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the replacement cost for the chair 
as currently configure is $5,920.56. The requested repair cost is $2,057.59, and the prior dollar history of 
repairs made to this wheelchair is $13,668.00. Based on this information, we decided that Medicare rules for 
coverage of a joystick mounting adapter, Gatlin midline mount, track mounted clamp, track nut, retractable or 
removable mounting hardware, and repairs or non-routine services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a joystick mounting adapter (K0108), Gatlin midline mount for 
quickie/quantum (K0108), track mounted clamp (K0108), track nut for sunrise chair (K0108), retractable or 
removable mounting hardware for joystick (E1028), and repairs or non-routine services for durable medical 
equipment other than oxygen equipment (K0739).