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

 
We decided that the Plan does not have to pre-approve Barostim Neo implantation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Barostim Neo was approved by the 
Food and Drug Administration (FDA) in 2019 for use in patients with refractory heart failure who remain 
symptomatic despite treatment with guideline-directed medical therapy, are New York Heart Association 
(NYHA) Class III, have an ejection fraction less than 35 percent, and are not candidates for bi-ventricular 
pacing. There remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Barostim Neo implantation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 1, 2022, to 
January 7, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, described as acute 
respiratory failure with hypoxia. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found that the enrollee presented with worsening shortness of breath and an 
increased oxygen requirement. He is noted to have had tachypnea, hypoxia, an ill appearance, coarse breath 
sounds and mild respiratory distress. The enrollee received increased levels of oxygen, antibiotics, steroids, 
nebulizers and continuous positive airway pressure. Given that the enrollee uses oxygen and continuous 
positive airway pressure at baseline, it would appear that he had acute on chronic respiratory failure.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 1, 2022, to January 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
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 clinical condition meets full IRF 
criteria. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous closure of patent foramen ovale 
(93580). 
 
You asked the Plan to pre-approve the percutaneous closure of patent foramen ovale. You say that the service 
is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the percutaneous closure of patent 
foramen ovale. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case.  Our physician reviewer found there is insufficient documentation to support the medical 
necessity for the requested PFO closure in this patients 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 the percutaneous closure of patent foramen ovale have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the percutaneous closure of patent foramen ovale 
(93580).
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 need rehab to regain strength to return home. 
The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements 
for approval. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment provided on January 5, 2023. 
 
You asked the Plan to pay for the oxygen equipment.. You say that you billed with valid diagnosis codes. The 
Plan denied your request. The Plan says you billed with an incorrect pair of diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that that ICD-10 codes with an Excludes1 note 
indicate it is a pure excludes note. An Excludes1 note indicates that the code excluded should never be used at 
the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur 
together.  
 
In this case, you billed the services at issue with diagnosis codes of J43.9 and J44.9. Code J44.9 has an 
Excludes1 relationship with diagnosis code J43.9, so these two codes cannot be billed together. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment. have not been met. Therefore, we decided that the Plan does not have to 
pay for the oxygen equipment provided on January 5, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. You say that your office does not carry the preferred products, but 
the enrollee completed a trial of physical therapy with only mild relief.  The Plan denied your request. The Plan 
says the enrollee has not tried and failed the preferred drugs. 
 
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 Gel-One. Our reviewer says that the 
enrollee does not meet the criteria for the requested drug, Gel-One. Our physician reviewer found the Plan 
requires a trial of drugs Monovisc, Orthovisc, Synvisc, or Synvisc One before they will approve the requested 
drug. The enrollee has not tried and failed the required drugs. There is no documentation provided indicating 
that the plans required drugs would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88104 billed for date of service January 18, 
2023. 
 You asked the Plan to pay for procedure code 88104. You say that this code is separately payable. The Plan 
denied your request. The Plan says payment for code 88104 is bundled into payment for code 88112. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88104 
is a column II code to column I code 88112. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we 
decided that the Plan does not have to pay for procedure code 88104 billed for date of service January 18, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a static or dynamic ankle-foot orthosis (AFO) (L4397). 
 
You asked the Plan to pre-approve an AFO. You say that the requested item is a medical necessity for you. The 
Plan denied your request. The Plan says the requested item 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 an AFO. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the provided records in this case do not document that you have a plantar flexion contracture of the 
ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); 
and there is a reasonable expectation of the ability to correct the contracture; and the contracture is interfering 
or expected to interfere significantly with your functional abilities; and the orthosis will be used as a 
component of a therapy program which includes active stretching of the involved muscles and/or tendons. 
 
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 AFO have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a static or dynamic ankle-foot orthosis (AFO) (L4397).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D conformal radiation therapy. 
 
You asked the Plan to pre-approve 3D conformal radiation therapy. You say that  the requested 3D conformal 
radiation therapy is medically necessary.  The Plan denied your request. The Plan says  the requested 3D 
conformal radiation therapy 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 3D conformal radiation therapy. Our 
reviewer says that the requested 3D conformal radiation therapy is not medically necessary.  Our physician 
reviewer found the use of radiotherapy to treat plantar fasciitis dates back many decades and is commonly 
practiced in Germany and other European countries.  While radiotherapy is not commonly utilized for plantar 
fasciitis in the United States (US), it is an effective treatment for which many US doctors (who would refer for radiation) are unfamiliar. However, it is an accepted standard for plantar fasciitis that is resistant to less 
invasive therapies. 
 
Radiation for treatment-resistant plantar fasciitis, based upon published literature and guideline statements 
(from Germany) would be considered to be furnished with accordance of accepted standards of care. However, 
the treatment prescribed to this enrollee is for electron therapy which would not be billed as 3D conformal 
radiotherapy. The decision for 3D conformal radiation is unfavorable; however, electron therapy would be 
favorable for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D conformal radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 3D conformal radiation therapy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that you need this injection. The Plan denied your 
request. The Plan says you have not failed the preferred products. 
 
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 looked at the file, and Medicare rules. The Plan requires a trial of Fulphila, Udenyca, Ziextenzo, or 
Nyvepria before they will approve the requested drug. The case file shows that the requesting provider will 
order one of the preferred products. There were no medical records provided to show that the Plans required 
drugs would likely be less effective or likely have adverse effects. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 documentation does not support the necessity for admission to an IRF. The 
complexity of your nursing, rehabilitation, and medical needs (combined complexity) does not require an acute 
hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While you may 
benefit from physical and occupational therapy, your rehabilitation needs can be provided in a lower intensity 
and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies billed with code A6197-A1 for date of service 
September 8, 2022. 
 
You asked the Plan to pay for the supplies. You say that you have provided records to support payment. 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 proof of delivery, You only supplied an order confirmation, but no 
information or documentation of delivery. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
supplies billed with code A6197-A1 for date of service September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for noninvasive ear or pulse oximetry for oxygen saturation; 
single determination rendered on October 10, 2022. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 
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 94760 is not supported in the medical record. Specifically, the status indicator for this 
code is "T" which means it should not be reported separately. 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 noninvasive ear or pulse oximetry for oxygen saturation; single determination rendered on 
October 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy with meniscectomy (29881). 
 
You asked the Plan to pre-approve a knee arthroscopy with meniscectomy. You say that the requested services 
are a medical necessity for the enrollee. 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 a knee arthroscopy with meniscectomy. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found that detailed documentation regarding a trial and failure of recent, 
reasonable, comprehensive, less invasive, conservative-care measures is not evident. The exam did not 
corroborate any significant mechanical symptoms of the left knee. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling 
rationale is presented or extenuating circumstances noted to support the medical necessity of the requested 
services as an exception. 
 
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 knee arthroscopy with meniscectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a knee arthroscopy with meniscectomy (29881).