Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 9, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement which indicates that these tests should be included in the dialysis rate. The Plan denied your request. 
The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
9, 2023.
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 would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements of 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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 a Vertiflex and stabilink. 
 
You asked the Plan to pre-approve a Vertiflex and stabilink. You say that this procedure is needed to help the 
enrollee with back pain. The Plan denied your request. The Plan says the requested services have been correctly 
denied. 
 
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 Vertiflex and stabilink. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a Vertiflex and stabilink is experimental., and more research is needed. 
 
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 Vertiflex and stabilink have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex and stabilink.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9375 billed for date of service January 1, 
2023 to January 6, 2023. 
 
You asked the Plan to pay for procedure code S9375. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9375 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9375 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9375 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9375 billed for date of service January 1, 2023 to January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid standard written order. Therefore, we decided that the Plan does not have to 
pre-approve a Group 2 power wheelchair (K0823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 6, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure (22612, 22840). 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure 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 the Minuteman procedure. Our 
reviewer says that the requested Minuteman procedure is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the current evidence-based medical guidelines and peer-reviewed 
literature do not fully support the interspinous fusion device procedure over the gold standard of lumbar 
fusion. The reviewer found there was no compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the reviewer found that the 
requested procedure 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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure (22612, 22840).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. The Plan denied your request. The Plan says 
the documentation does not indicate that the member requires frequent and immediate need for a change in 
body position to qualify for a semi-electric hospital bed.  
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found that the documentation 
doesnt support that you have a condition that requires frequent positioning of the bed and mattress to alleviate 
pain, promote good body alignment, prevent contractures or avoid respiratory infections in a way that an 
ordinary bed is not able to. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T12 and L5. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested procedure is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is considered reasonable and necessary for 
osteoporotic conditions when the enrollee has an acute or subacute VCF, is symptomatic, and has been 
hospitalized for severe pain. The rules also say that the enrollee must not have any listed contraindications.  
 
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 kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that there is no documentation of an 
adequate trial of fracture bracing. More conservative measures are needed. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at T12 and L5.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90832 billed for date of service September 
22, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the claim was 
not received 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 billed services was not filed until November 15, 2022. 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 procedure code 90832 billed for date of service September 22, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. 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 stress testing with cardiac imaging will be considered 
medically reasonable and necessary when specific 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 myocardial perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22513. 22514, 
22515). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the enrollee's pain is 
progressing and has inability to do daily activities or household activities due to the pain. The pain is 
progressively getting worse, and the enrollee has trouble with daily living activities and caring for herself due 
to the level of pain. The Plan denied your request. The Plan says the enrollee does not meet requirements for 
approval. 
 
The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for percutaneous 
vertebral augmentation to be 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 percutaneous vertebral augmentation. 
Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed 
documentation is not evident regarding the specific levels the percutaneous vertebral augmentation is being 
requested. Without clear indication which levels, the age of the compression fracture cannot be determined to 
be acute or subacute. The diagnostic imaging revealed both acute and chronic compression fractures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation (22513. 22514, 22515).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate artery embolization (PAE) (37243 x 2) provided 
from August 29, 2022, to September 6, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this procedure is indeed covered by Medicare 
for your condition. You say that you were shocked to find that although all the preparations and peripherals to 
the procedure were reimbursed, the actual intricate procedure was not. You say that this bill is very stressful. 
The Plan denied your request. The Plan says the services were 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 pay for the surgical service. Our reviewer says that 
the prostate artery embolization (PAE) are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the procedure at issue in this case is considered experimental at this time for the treatment of benign prostate hypertrophy (BPH). Therefore, the reviewer found that this procedure is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pay for the prostate artery embolization (PAE) (37243 x 2) provided from August 29, 2022, to 
September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient psychiatric admission provided on January 17, 
2023, to January 23, 2023. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that there is no safe place to 
discharge the enrollee, and the enrollee was not capable of being discharged. The Plan denied your request. The 
Plan says these services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient psychiatric hospital services. Our 
reviewer says that the medical criteria for an inpatient psychiatric admission have not been met. Our physician 
reviewer found it did not appear that active treatment was taking place beyond January 16, 2023. It did not 
appear that the services for January 17, 2023, to January 23, 2023, were reasonably expected or medically 
necessary to improve the enrollee's condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan does not have to pay for an inpatient psychiatric admission provided on January 17, 2023, to 
January 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nplate (romiplostim) (J2796). 
 
You asked the Plan to pre-approve Nplate. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the requested use is not supported by the Food and Drug 
Administration (FDA) for the enrollee's condition. 
 
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 Nplate. Our reviewer says that the 
requested use of Nplate is not medically necessary. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. Therefore, the reviewer found that the requested use of Nplate 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 Nplate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nplate (romiplostim) (J2796).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9351, S9375, and S8379 billed for date of 
service January 1, 2023, to January 6, 2023. 
 
You asked the Plan to pay for procedure codes S9351, S9375, and S8379. You say that per your contract, these 
codes are correct. The Plan denied your request. The Plan says the billed codes are invalid for Medicare 
purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes S9351, S9375, and S8379 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes S9351, S9375, and S8379 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes S9351, S9375, and 
S8379 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes S9351, 
S9375, and S8379 billed for date of service January 1, 2023, to January 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single-photon emission computerized tomography 
(SPECT) parathyroid planar imaging (78071). 
 You asked the Plan to pre-approve SPECT parathyroid planar imaging. You say that you want the Plan to 
approve the service. The Plan denied your request. The Plan says the medical records are from the primary care 
provider and make no mention of a specialty surgery referral or consultation or plan for surgical intervention. 
 
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 SPECT parathyroid planar imaging. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the limited documentation provided there is no evidence of 
the enrollee's symptoms or complications. There is no documentation of the enrollees medical conditions or 
medications. There is no evidence of a physicians examination, assessment or plan. There is no evidence of 
additional laboratory testing, basic imaging, or specialist evaluation. As such, there is insufficient evidence to 
show that the requested test 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 SPECT parathyroid planar imaging have not been met. Therefore, we decided 
that the Plan does not have to pre-approve single-photon emission computerized tomography (SPECT) 
parathyroid planar imaging (78071).