Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital admission for an elective left total 
shoulder arthroplasty (23470-LT). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is medically necessary. The 
Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical 
clearance to undergo this elective procedure. The Plan states the planned procedure listed under code 23470 is 
not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the 
procedure is currently approved as an ambulatory procedure and there is no documentation provided to support 
the expectation the enrollee will require a greater than two (2) midnight stay.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation did not support hospital services for this typically 
ambulatory procedure. The enrollee did not have an unstable condition or expectation for a prolonged recovery 
or other indication for inpatient status. There is no expectation that the enrollee will need hospital care that will 
likely cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital admission for an elective left total shoulder arthroplasty 
(23470-LT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
September 14, 2022, to October 4, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the equipment was prescribed 
by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your request. The 
Plan says that a pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis 
during and/or following surgery. 
 
 The Plan must follow Medicare rules. The rules state that a PCD that provides intermittent limb compression 
for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say 
that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on September 14, 2022, to October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery 
pressure monitor. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that the requested treatment is proven 
to reduce hospitalizations.  The Plan denied your request. The Plan says the literature is not sufficient to 
support the medical necessity of the CardioMEMS 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 the CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a lack of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate 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 the CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery pressure monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-FACTOR peptide enhanced bone graft (20930). 
 
You asked the Plan to pre-approve i-FACTOR peptide enhanced bone graft. 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 i-FACTOR peptide enhanced bone 
graft. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found I factor graft is experimental. 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 i-FACTOR peptide enhanced bone graft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve i-FACTOR peptide enhanced bone graft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says there are in-network pain management specialists readily 
available and accessible to the member. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided from January 25, 2023, 
to February 3, 2023.  
 
You asked the Plan to pay for inpatient mental health care. You say that this was medically necessary. The Plan 
denied your request. The Plan says the enrollee no longer needed inpatient care.  
 
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 mental health care. Our reviewer 
says that the inpatient care at issue was not medically necessary. Our physician reviewer found the records 
show that the enrollee did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or 
abnormal behaviors during the dates at issue. The enrollee could have been treated in a less restrictive setting. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient mental health care provided from January 25, 2023, to February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
August 31, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 87481 and 87653 is bundled into 
payment for code 87801. 
 
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 87481 
and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for date 
of service August 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exploration of the spinal fusion (22830). 
 
You asked the Plan to pre-approve exploration of the spinal fusion. 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 exploration of the spinal fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found exploration of spinal fusion code can not be billed at the same level of a cervical fusion. The fusion has already been 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 exploration of the spinal fusion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve exploration of the spinal fusion (22830).
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 are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute IRF setting 
have 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery for L3-4 and L4-5 anterior lumbar interbody 
fusion (20930, 22558, 22585, 22843, 22845, 22853).  
 
You asked the Plan to pre-approve the services. You say that your left leg goes numb and can cause falls.  The 
Plan denied your request. The Plan says the fusion surgery would be medically necessary in this case if there 
were a request for destabilizing facet joint removal to adequately decompress the severe foraminal stenosis 
from a posterior approach. The Plan states there is no request for posterior surgery which would cause 
iatrogenic instability.  
 
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 services. Our physician reviewer 
found there is no documented spinal instability, fracture, or lesion. The fusion is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgery for L3-4 and L4-5 anterior lumbar interbody fusion (20930, 22558, 22585, 22843, 
22845, 22853).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210 x7). 
 
You asked the Plan to pre-approve the dental services. You say that in order to get dentures, you will need to 
get these extractions done. You say are on antibiotics for the pain and cannot eat. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on June 14, 2023 when the Plan authorized 
three extractions. Therefore, we decided that the Plan does not have to pre-approve extractions (D7210 x7).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required  
(D2950 x 4). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
enrollee's supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental items are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildups, including any pins when required (D2950 x 4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95937, 95927, 95907, 95955, and 95885 for 
date of service October 5, 2021. 
 
You asked the Plan to pay for procedure codes 95937, 95927, 95907, 95955, and 95885. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported.  

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 codes 95937, 95927, 95907, 95955, and 95885 are not supported in the medical record. 
Specifically, the technical report did not include documentation of neuromuscular junction testing; therefore, 
code 95937 cannot be verified. The technical report did not include documentation of a short-latency 
somatosensory evoked potential study; therefore, code 95927 cannot be verified. 
 
The technical report did not include documentation of nerve conduction studies; therefore, code 95907 cannot 
be verified. The technical report did not include documentation of an electroencephalogram; therefore, code 
95855 cannot be verified. The technical report did not include documentation of a limited needle 
electromyography; therefore, code 95885 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 95937, 95927, 
95907, 95955, and 95885 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 95937, 95927, 95907, 95955, and 95885 for date of service October 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva (J0897). 
 
You asked the Plan to pre-approve Xgeva. You say that you believe Xgeva is the best treatment choice for the 
enrollee's hypercalcemia at this time. The Plan denied your request. The Plan says treatment with Xgeva for a 
diagnosis of unspecified hypercalcemia is not supported by any of the compendia, by two published articles, or 
by evidence-based guidelines/other standards of medical practice. 
 
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 Xgeva. Our reviewer says that Xgeva is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of hypercalcemia not associated with malignancy. The FDA has not stated that the 
requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that the 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (J0897).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75716 and 75774 billed for date of service 
November 8, 2022. 
 
You asked the Plan to pay for procedure codes 75716 and 75774. You say that these services were reported 
correctly and are supported in the medical records. The Plan denied your request. The Plan says the payment 
for these services is included in the payment for code 37211. Although modifiers were reported with these 
codes, the records do not support that these were applied accurately. 
 
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 75716 and 75774 is a column II code to column I code 37211; 
however, 75716 and 75774 was billed with a modifier.  
 
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 procedure codes 75716 and 75774. Our reviewer says that 
these services are not supported for separate reporting in this case. Our reviewer found the procedure report 
describes an intervention performed, which includes radiological and interpretation. Therefore, these imaging 
services would be included in the intervention service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 75716 and 75774 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 75716 and 75774 billed for date of service November 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282, S9999) provided on October 25, 2022. 
 
You asked the Plan to pay for the wig. You say that this item was medically necessary. The Plan denied your 
request. The Plan says the wig and the associated sales tax are not eligible for coverage under Medicare rules. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282, S9999) 
provided on October 25, 2022.
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 17, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, 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 
17, 2023.