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

 
We decided that the Plan does not have to pre-approve percutaneous implantation of peripheral nerve 
stimulation. 
 
You asked the Plan to pre-approve percutaneous implantation of peripheral nerve stimulation. You say that 
percutaneous implantation of peripheral nerve stimulation is medically necessary based on the patient's current 
medical status and available data. The Plan denied your request. The Plan says percutaneous implantation of 
peripheral nerve stimulation does not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 implantation of peripheral 
nerve stimulation. Our reviewer says that percutaneous implantation of peripheral nerve stimulation is not 
considered medically necessary. Our physician reviewer found the enrollee has chronic low back pain. The 
enrollee had limited improvement with medial branch rhizotomy, an excellent response to prior percutaneous electrical stimulation and the physician is requesting repeat percutaneous electrode implant stimulation. The 
enrollee has had lumbar medial branch block, multiple transforaminal epidural steroids, rhizotomy, physical 
therapy, a home exercise program, chiropractic therapy, massage, acupuncture, medications, x-ray of the 
lumbar spine. There is lateral listhesis at L2-3 and L1 that is moderate. There is an anterolisthesis of L3-4 and 
L4-5 of 5-6 mm. Advanced disc space narrowing is noted at L5-51 and L4-5 and L2-3. The magnetic resonance 
imaging (MRI) of the lumbar spine shows severe stenosis central at L4-5 associated with degenerative 
spondylolisthesis and advanced facet arthropathy and there is a right-sided laminotomy. This is considered 
experimental therapy. 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 percutaneous implantation of peripheral nerve stimulation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of peripheral 
nerve stimulation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the additional two visits are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have continued skilled nursing needs. The enrollee also does not require continued home 
observation, education, or treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two additional skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis at L4-5. 
 
You asked the Plan to pre-approve arthrodesis. You say that the enrollee is in a lot of pain. The Plan denied 
your request. The Plan says evidence was not provided to show that this procedure is 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 arthrodesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding potential impending/inevitable temporary intra-
operative instability. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. There is no compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request 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 arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis at L4-5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state provided on February 
23, 2023. 
 
You asked the Plan to pay for the vision service. You say that this should have been a routine eye exam. You 
also say that you should not have any copayments or be charged for the refraction. The Plan denied your 
request. The Plan says refractions are not covered for diagnostic eye exams. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed with a routine eye exam. 
 
We looked at the file and the Plan's rules. This service is covered when performed with a routine eye exam. 
Based on this information, we decided that the Plan's rules for coverage of the vision service have not been 
met. Specifically, the file indicates that a diagnostic eye exam was performed on this date of service. 
Additionally, this means that you have been asked to pay the $20 copayment amount based on 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 determination of refractive state provided on 
February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the NutrEval nutritional testing (84999) provided March 1, 
2022, to March 30, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this is diagnostic test which should have 
been covered and you were forced to pay up front.  The Plan denied your request. The Plan says the testing 
does not meet the definition of medical necessity. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was insufficient support made for this test panel to be medically necessary for 
this enrollee as there was no reported symptoms or findings suggesting a nutrient deficiency, nor was there 
support provided for a clinical use of organic acid testing for the conditions listed for this enrollee. Therefore, 
this request for NutrEval will be considered not medically 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the NutrEval nutritional testing (84999) provided March 1, 2022, to March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service January 3, 
2023. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not payable as billed. 
 
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 this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there 
is only a technical component for the CPT code. This indicator identifies stand alone codes that describe the 
technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an 
associated code that describes the professional component of the diagnostic tests only. In this case, CPT code 
99153 is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99153 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99153 billed for date of service January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test (81529) provided on January 
17, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that your claim for the DecisionDx-Melanoma test 
was denied in error and you are requesting it be reprocessed and paid. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-Melanoma test (81529) provided 
on January 17, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87491 billed for date of service February 28, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the coding is approved by Medicare. The Plan 
denied your request. The Plan says the documentation does not support the code. 
 
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 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. 

We find that CPT code 87491 is not supported in the medical record. The records do not show that the lab test 
at issue was provided. 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 87491 
billed for date of service February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three hundred (300) intermittent urinary catheters; 
straight tip (A4351). 
 
You asked the Plan to pre-approve urinary straight catheters. You say that you need the requested number of 
catheters due to being paralyzed and having bladder problems. The Plan denied your request. The Plan says 
you have exceeded the maximum quantity of catheters allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that the urinary straight catheters are provided at a 
maximum quantity of 200 per month.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of urinary straight catheters have not been met. Specifically, the requested catheters are provided at a 
maximum quantity of 200 per month. The Plan has confirmed that 200 catheters were already approved for a 
total of 2400 for the year. Therefore, we decided that the Plan does not have to pre-approve three hundred (300) 
intermittent urinary catheters; straight tip (A4351).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and two footplate width extension brackets (K0108 x2).  

You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and two footplate 
width extension brackets. You say that the enrollee is non-ambulatory without the requested durable medical 
equipment and subject to skin breakdown. The Plan denied your request. The Plan says although there are three 
requested power options (tilt, recline and elevating leg rests), there is not a medical need to control these power 
options through the joystick. The Plan also says code K0108 cannot be approved, as this is incorrectly coded 
and unbundled, and these items still do not meet the coverage criteria. 
 
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 electronic connection, harness, 
expandable controller, and two footplate width extension brackets. 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 adequate upper body strength to manage standard power drives. Our reviewer also found 
that the requested footrests are unbundled and incorrectly coded as there is a HCPCS code for the footrests.  
 
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 electronic connection, harness, expandable controller, and two footplate 
width extension brackets have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an electronic connection (E2311), harness (E2313), expandable controller (E2377), and two footplate width 
extension brackets (K0108 x2).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
the requested complex power wheelchair is the most appropriate and lowest-cost alternative for the enrollee to 
safely meet their daily needs independently. The Plan denied your request. The Plan says that although there 
are three requested power options (tilt, recline and elevating leg rests), there is not a medical need to control 
these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) is medically necessary. Our physician reviewer found the expandable controller 
with harness and electronic connection are necessary to operate the group 3 power wheelchair base and the 
three power options via a joystick. Our reviewer also found that these components are required to operate 3 or 
more power options on a group 3 power wheelchair. 
 
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 electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition 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 enrollee does 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not 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. 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 pre-approve a home ventilator (E0466).  
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of a ventilator. 
 
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. 
 
 
 
 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and 
obstructive sleep apnea and was recently hospitalized with an acute exacerbation of COPD. An arterial blood 
gas (ABG) done on July 14, 2023, is consistent with mild acute but not chronic hypercarbic respiratory failure. 
There is no ABG done while stable to document chronic carbon dioxide (CO2) retention. There are no 
pulmonary function tests to assess the severity of the COPD. If this enrollee does have chronic CO2 retention, 
she may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support 
(AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that 
can be provided with BiPAP. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 28, 
2023. 
 
You asked the Plan to pre-approve SNF care. You say that the continued SNF care is medically necessary. The 
Plan denied your request. The Plan says that the continued SNF care is not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before July 28, 2023. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after July 28, 2023.  
 
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.