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

 
We decided that the Plan has to pre-approve nasopharyngoscopy with balloon sinuplasty, partial 
ethmoidectomy, and Eustachian tube dilation. 
 
You asked the Plan to pre-approve sinus surgery. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that that the enrollee does not meet medical necessity criteria for this request. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 sinus surgery. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records in this case document chronic sinusitis and symptoms of Eustachian 
tube dysfunction for greater than 6 months. Records document mild paranasal sinus mucosal thickening on 
computed tomography and records document treatment with saline lavage, Flonase since at least January 2023, 
a course of treatment with doxycycline and Augmentin, and five days of an oral steroid (stopped due to side 
effects). Provided records document failure of medical therapy to manage the enrollees condition and 
symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sinus surgery have been met. Therefore, we decided that the Plan has to pre-
approve nasopharyngoscopy with balloon sinuplasty, partial ethmoidectomy, and Eustachian tube dilation.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided from May 18, 2023, 
to June 7, 2023. 
 You asked the Plan to pay for the billed services. You say that the claims should be processed as in-network. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The file shows that you received lab testing and an x-ray on May 18, 2023. You were charged a 40% 
coinsurance for the lab services and a $10 copay for the x-ray. The services fall within the outpatient diagnostic 
tests benefit category. 
 
You received surgery services and a drug injection on May 24, 2023. You were charged a 40% coinsurance for 
the drug and a $285 copay for the outpatient surgery services. The services fall within the Medicare Part B 
prescription drugs and outpatient surgery benefit categories.  
 
You received lab services on June 7, 2023. You were charged a 40% coinsurance for the lab services. The 
services fall within the outpatient diagnostic tests benefit category.  
 
We looked at the file and the rules. The services you received on each date were provided at an out-of-network 
facility. Previously, services you received from an out-of-network provider were processed with an in-network 
rate due to the public health emergency (PHE). However, the services at issue in this case were received after 
the PHE ended. You have been asked to pay the correct amount based on the out-of-network benefits in your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided 
from May 18, 2023, to June 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) G0416 billed for date of service June 16, 
2023. 
 You asked the Plan to pay for procedure code(s) G0416. You say that this claim was billed correctly and you 
have provided medical records. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) G0416. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) G0416. Based on this information, 
we decided that Medicare rules for coverage of procedure code G0416 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) G0416 billed for date of service June 16, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ten units of procedure code 75774 rendered on March 23, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no specific rationale as required as to why additional units needed to be performed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 75774 is "Angiography, selective, each additional vessel 
studied after basic examination, radiological supervision and interpretation (List separately in addition to code 
for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that a total of 10 units were billed for 
selective arterial catheter placements, but Medicare's daily limit for CPT 75774 is 7 units. There must be a 
specific explanation for the additional three units. There was no such explanation in the records for why the 
extra units were medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. 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 ten units of procedure code 75774 rendered on March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and non-pneumatic sequential compression garment, full leg (K1032). 
 
You asked the Plan to pre-approve a non-pneumatic compression device and garment. You say that the 
requested device is medically necessary for the enrollee. The Plan denied your request. The Plan says it is not 
reasonable and necessary to use the requested treatment for lymphedema. 
 
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 non-pneumatic compression device 
and garment. 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 medical records provided, there is no 
documentation that the Koya Dayspring non-pneumatic compression device at issue in this case meets all 
Medicare criteria for medically reasonable and necessary and safe and effective for the enrollee. Provided 
records in this case document the enrollee's edema is "quite stable" and she has had "great results with manual 
lymphatic massage therapy and her daughter has been helping her with the massage techniques." Later notes 
indicate the enrollee voluntarily stopped using her compression stockings and her edema has worsened but she 
still receives benefit from the manual lymphatic massage. Overall, records do not show an adequate trial and 
failure of conservative measures to control the enrollee's lymphedema. 
 
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 non-pneumatic compression device and garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a non-pneumatic compression controller with 
sequential calibrated gradient pressure (K1024) and non-pneumatic sequential compression garment, full leg 
(K1032).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Eylea. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has macular edema following retinal vein occlusion. The documentation does not support 
that the enrollee has tried and failed the ophthalmic formulation of bevacizumab. The documentation does not 
support that the ophthalmic formulation of bevacizumab would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for you to 
regain your maximum function. The Plan denied your request. The Plan says your medical condition requires 
further evaluation and treatment in the acute care hospital. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. Your condition is complex and fragile, and there is every reason to expect that you will participate 
in and benefit from IRF-level services to include at minimum therapy services, physician oversight of 
polypharmacy and case manager coordination of any additional services that might be needed to make a 
sustainable return home, as well as avoid preventable readmissions to the acute hospital. It is highly unlikely 
that your needs could be met at a lower level of care. Therefore, the requested inpatient rehabilitation facility 
admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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 requested IRF services are  medically necessary. 
The Plan denied your request. The Plan says an IRF stay exceeds your level of need.  
 
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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for a fall and rhabdomyolysis. Your medical problems are stable. 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 therapy and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 14, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this is not covered by Medicare. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive, with image guidance, includes obtaining bone graft when performed, and placement of transfixing 
device (27279). 
 
You asked the Plan to pre-approve sacroiliac (SI) joint fusion. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of this 
procedure. 
 
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 sacroiliac (SI) joint fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records show there is no SI joint instability, fracture, or lesion. SI 
fusion for degenerative back pain is experimental and/or investigational. 
 
 
 
 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 (SI) joint fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image 
guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 full criteria for an inpatient 
acute rehabilitation stay, which is needed for rehabilitation to maximize the potential to return to previous level 
of independence. The Plan denied your request. The Plan says the enrollee  must have completed the full 
course of treatment in the current referring hospital. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's medical records overall significantly complies with the various documentation 
requirements for IRF admission. The enrollees condition is in fact complex and fragile, and there is every 
reason to expect  participation in and benefit from IRF level services to include at minimum physical and 
occupational therapy, physician oversight of wound care and polypharmacy, and case manager coordination of 
any additional services that might be needed to make a sustainable return home, as well as avoid preventable 
re-admissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627) and durable medical 
equipment (DME), miscellaneous (E1399). 
 
You asked the Plan to pre-approve a seat lift mechanism and miscellaneous DME. You say that you have 
reported pain in your knee and had one replace but you stopped seeing your pain specialist. You also say you 
need the seat lift because you have gained weight and do not want to have surgery. The Plan denied your 
request. The Plan says you do not meet criteria for approval of the requested device. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a seat lift mechanism and miscellaneous DME have not been met. Specifically, per LCD 33801, a 
seat lift is only covered if you have limited mobility due to severe arthritis of your hip or knee or a severe 
neuromuscular disease. The records show you have limited mobility due to low back pain and obesity. 
Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627) and durable 
medical equipment (DME), miscellaneous (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrophysiology study with catheter ablation 
(93654). 
 
You asked the Plan to pre-approve an electrophysiology study with catheter ablation. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electrophysiology study with 
catheter ablation. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is insufficient documentation at this time to 
support the medical necessity for an electrophysiologic study with catheter ablation in your 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 an electrophysiology study with catheter ablation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an electrophysiology study with catheter ablation 
(93654).