Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 00300-AA-P4. We decided 
that the Plan does not have to pay for the services described by procedure code(s) 99100-GY.  
 
You asked the Plan to pay for practitioner services provided on June 22, 2023, billed with procedure codes 
99100-GY and 00300-AA-P4. You say that the claim is billed correctly and should be paid. The Plan says that 
the service is considered bundled and is not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 00300-AA-P4.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 00300-AA-P4.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100-GY. 
 
The Plan follows Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator B means 
that payment for covered services is always bundled into payment for other services not specified.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99100-GY have not been met. Therefore, we decided 
that the Plan does not have to pay for the services described by procedure code(s) 99100-GY. 
 
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 the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the notes do not show a medical need to control the 
power options through the joystick. 
 
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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that the enrollee has adequate strength to 
manage standard power drives. Therefore, the reviewer found that the requested upgraded electronics are 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 rendered on September 29, 2021. 
 
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 this was not reported properly. 
 
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 64450 is ""Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch." 
 
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 the medical records provided 
indicate the physician used a block along with general anesthesia preoperatively. An epidural or peripheral 
nerve block injection (64400 - 64530) administered preoperatively or intraoperatively is not separately 
reportable for postoperative pain management if the mode of anesthesia for the procedure is monitored 
anesthesia care, moderate conscious sedation, regional anesthesia by peripheral nerve block. Therefore this 
64450 is not eligible for reimbursement consideration. 
 
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 procedure code 64450 rendered on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single axis, fluid swing and stance phase control 
(L5828) stance flexion feature, adjustable (L5845) fluid stance extension, dampening feature, with or without 
adjustability (L5848) knee extension assist (L5850) microprocessor control feature, swing and stance phase, 
includes electronic sensor(s), any type (L5856) flex-walk system or equal (L5981) All lower extremity 
prostheses, multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve the advanced prosthetic components. You say that please review your 
appeal request and make the appropriate decision to approve the prior authorization request. The Plan denied 
your request. The Plan says the requested prosthesis/prosthetic parts exceed the member's need and cannot be 
approved. 
 
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 advanced prosthetic components. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found a wheelchair was requested and approved on October 4, 2023. The 
enrollee's transfer style includes to stand pivot transfer. A walker is used to assist with transfers and the 
transfers are performed with caregiver assistance. The enrollee cannot transfer independently due to weakness. 
The requested prosthetic components are not medically necessary as the physician documentation does not 
support that the enrollee is a K3 ambulator. The documentation notes that the enrollee will use a cane or walker 
once fitted with a prosthesis. 
 
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 advanced prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve single axis, fluid swing and stance phase control (L5828) stance 
flexion feature, adjustable (L5845) fluid stance extension, dampening feature, with or without adjustability 
(L5848) knee extension assist (L5850) microprocessor control feature, swing and stance phase, includes 
electronic sensor(s), any type (L5856) flex-walk system or equal (L5981) All lower extremity prostheses, 
multi-axial rotation unit (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Via Disc procedure. 
 
You asked the Plan to pre-approve the Via Disc procedure. You say that the enrollee has received a number of 
shots in their lower back over the years with some temporary pain relief. You say that this procedure would be 
beneficial. The Plan denied your request. The Plan says the Via Disc procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Via Disc procedure. Our reviewer 
says that the Via Disc procedure is not medically necessary. Our physician reviewer found that there is little 
evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. 
The Via Disc procedure is not an accepted standard of medical practice for the diagnoses or treatment of back 
pain. The requested injection of allograft into the intervertebral disc for the treatment of degenerative disc 
disease, is considered experimental and investigation. Therefore, the Via Disc procedure is considered 
investigational and not medically necessary for the treatment of degenerative disc disease. 
 
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 Via Disc procedure. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Via Disc procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has bad bed soars and 
delirium. You say that some rehabilitation facilities will not take the enrollee due to the higher medical needs, 
and they need a long-term care facility. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting and the 
documentation does not support that LTACH services are medically appropriate at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amnioexcel, Amnioexcel plus or Biodexcel, per square 
centimeter (Q4137). 
 
You asked the Plan to pre-approve a skin substitute. You say that you are asking for reconsideration because 
the enrollee had a basal cell carcinoma that invaded the bone. It is medically necessary the enrollee receives the 
amnioexcel for his wound. The Plan denied your request. The Plan says there are not enough studies on 
AmnioExcel to show it is safe and effective. 
 
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 skin substitute. 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 basal cell carcinoma of the nose invading the bone. A request was made for 
AmnioExcel (skin substitute). However, review of the currently published literature on this product does not 
show sufficient high-quality studies to support its use in this clinical scenario compared to other similar 
products. There is insufficient evidence to show its safety and effectiveness to support this request at this time. 
Therefore, the AmnioExcel 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 skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Amnioexcel, Amnioexcel plus or Biodexcel, per square centimeter (Q4137).
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 meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the request is not medically necessary.  
 
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 do 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: 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 admission is a medical necessity. The Plan denied 
your request. The Plan says based on the available information, admission to IRF is not reasonable and 
necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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. The patient was 
admitted for COVID-19 infection, influenza, urinary tract infection and cervical fractures after a motor vehicle 
accident. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 the nursing facility visit provided on March 16, 2023. 
 
You asked the Plan to pay for the nursing facility visit. You say that the services should be considered for 
payment due to medical necessity. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nursing facility visit 
provided on March 16, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 13121 and 13122(x2) billed for date of service August 
31, 2023. 
 
You asked the Plan to pay for procedure codes 13121 and 13122(x2). You say that these services were 
necessary and were reported correctly for separate payment. The Plan denied your request. The Plan says that 
these services are not supported for separate payment in this case. 
 
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 13121 
and 13122 is a column II code to column I code 24077; however, 13121 and 13122 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 13121 and 13122(x2). Our reviewer says 
that although there is a billing error on this claim, the codes at issue are supported for separate payment. Our 
reviewer found that the codes at issue are supported as separately identifiable procedures and are not included 
in the main procedure. The record states that extensive undermining was performed, which meets the definition 
of complex closure. In addition, 24077 is not the appropriate code for the main procedure. The rules state that 
codes 11600-11646 should be used for radical resection of tumors of cutaneous origin (e.g. melanoma). There 
is no NCCI edit between 11606 and 13121. 
 
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 13121 and 13122(x2) have been met. Therefore, we decided 
that the Plan has to pay for procedure codes 13121 and 13122(x2) billed for date of service August 31, 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.
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 cannot be safely discharged home. You are 
unable to walk and require IRF services to regain your prior level of functioning. The Plan denied your request. 
The Plan says the request is not medically necessary.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 pre-approve a MyoPro arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro arm brace. You say that the MyoPro device is approved by 
Medicare and should be covered for the enrollee. The Plan denied your request. The Plan says there are not 
enough studies to show MyoPro is safe and effective to help the enrollee recover from his disability. 
 
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 MyoPro arm brace. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device is used for the upper extremity. It is an arm brace that is 
motorized and can help an enrollee with upper extremity weakness to move their arm and hand. The requested 
device has not been shown to be superior to other standard treatments for the medical condition. The studies do 
not indicate the MyoPro brace improves an enrollees function or general health. The requested device is 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 a MyoPro arm brace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro arm brace (L8702).