Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and atrial fibrillation. He was hospitalized on April 21, 2023 with acute respiratory 
failure requiring intubation. A follow-up outpatient visit on May 18, 2023 noted a  forced expiratory volume in 
one second (FEV1) of less than 50 percent of predicted, but full pulmonary function results are not provided. 
There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) retention. 
The criteria for coverage are not met and the ventilator is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radionuclide stress test. 
 
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 stress testing is covered when specific criteria are 
met. 
 
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 enrollee has no cardiac symptoms. 
There is no documentation that an electrocardiogram (ECG) showed an uninterpretable pattern or that the 
enrollee is unable to exercise. The criteria for coverage are not met and the requested stress test is not 
reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a radionuclide stress test.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a sacroiliac joint (SIJ) injection (27096). 
 
You asked the Plan to pre-approve a SIJ injection. You say that the enrollee had a positive FABER test on the 
right side, a positive thigh thrust test on the right side, and a positive Yeoman's test on the right side.  The Plan 
denied your request. The Plan says that the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when certain criteria have been met. 
 
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 SIJ injection. Our reviewer says that 
the requested SIJ injection is medically necessary. Our physician reviewer found the provided documentation 
does not support objective physical exam signs of radiculopathy. The reviewer found that sacroiliac (SI) joint 
pain may extend to the gluteus muscle and the posterior thigh. Therefore, the reviewer found that the requested 
SIJ injection is 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 a SIJ injection have not been met. Therefore, we decided that the Plan has to 
pre-approve a sacroiliac joint (SIJ) injection (27096).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the lab testing billed for date of 
service February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve he Baroreflex Stimulation device (0266T) and generator 
(C1825). 
 
You asked the Plan to pre-approve the Baroreflex Stimulation device and generator. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the Baroreflex Stimulation device and 
generator are considered experimental. 
 
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 Baroreflex Stimulation device and 
generator. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Baroreflex Stimulation device and generator are considered 
experimental.  
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 Baroreflex Stimulation device and generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve he Baroreflex Stimulation device (0266T) and generator 
(C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve ablation. 
 
You asked the Plan to pre-approve the genicular nerve ablation. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is considered experimental. 
 
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 genicular nerve ablation. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case.  
Our physician reviewer found this therapy is the subject of ongoing clinical trials and is considered 
experimental at this point in 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 genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that there is a 
medical certification which informs you that if you have a medical condition and need transportation because 
you continue with therapies all year round, you have the right to services for the condition in which you are. The Plan denied your request. The Plan says the evidence shows that you have used thirty (30) one-way trips of 
the thirty (30) one-way trips covered by the Plan for the year 2023. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
non-emergency transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional non-emergency transportation trips (A0100).
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 45385. We decided that the Plan does not have to pay 
for procedure code 45381.  
 
You asked the Plan to pay for procedure codes 45381 and 45385 billed for date of service December 7, 2022. 
You say that the services at issue have been billed correctly. The Plan says that the provided records do not 
support the services billed.  
We decided that the Plan has to pay for procedure code 45385.  
 
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 45385 is: Colonoscopy, flexible; with removal of 
tumor(s), polyp(s), or other lesion(s) by snare technique. 
 
We asked our coder 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 procedure codes 45381 and 45385. Our 
reviewer says that procedure code 45385 does meet criteria for payment. Our coder reviewer found that the 
procedure report describes polyp removal by snare technique. 
 
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 code 45385 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 45385.  
 
We also decided that the Plan does not have to pay for procedure code 45381. 
 
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 45381 is: Colonoscopy, flexible; with directed 
submucosal injection(s), any substance 
 
We asked our coder 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 procedure code 45381. Our reviewer says 
that procedure code 45381 does not meet criteria for payment. Our coder reviewer found that the procedure 
report does not include documentation of directed submucosal injection(s). This procedure was not found in 
medical record, and therefore cannot be verified. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 45381 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 45381. 
 
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter. 
 
You asked the Plan to pre-approve a scooter. You say that you have a pinched nerve in your back, the pain goes 
all the way down to your right foot, your right leg is crooked, and you cannot walk without a walker. The Plan 
denied your request. The Plan says medical necessity has not been established for the requested durable 
medical equipment. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 scooter. Our reviewer says that you 
do not meet the coverage criteria for a scooter. Our physician reviewer found the documentation does not 
reveal clear evidence of a mobility deficit that impairs MRADLs in the home and is unable to be relieved by as 
assistive device. Our reviewer also found that the documentation does not reveal a home evaluation indicating 
that the home has maneuvering space for the requested scooter and that you can use it safely.  
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99223) provided on December 13, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 99223 is initial hospital care, evaluation 
and management of a patient, requiring a comprehensive history, a comprehensive examination and medical 
decision making of 
high complexity. 
 
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 inpatient care. Our reviewer says that the records do not 
support the billed service. Our reviewer found there was no documentation of medical decision making of high 
complexity. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for inpatient care (99223) provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart system. 
 
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 Optimizer Smart device was 
approved by the Food and Drug Administration (FDA) in 2019 but remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Optimizer Smart system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Percutaneous Vertebral Augmentation (22510, 22513, 
22511). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation for 
Osteoporotic Vertebral Compression Fracture is covered when 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 the procedure. Our reviewer says that 
this procedure is not medically necessary. Our physician reviewer found the records do not show sufficient 
conservative treatment. There is no record of a trial of bracing being performed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Percutaneous Vertebral Augmentation (22510, 22513, 22511).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96132).  
 
You asked the Plan to pre-approve neuropsychological testing. You say that the requested service is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the provided documentation does not 
include evidence of diseases that affects the brain, central nervous system or psychiatric disorders.  
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing may be necessary when 
intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or 
indirectly on the brain. 
 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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not medically necessary. Our physician reviewer 
found the provided documentation does not support that the enrollee has shown severe impairment of their 
memory and has not affected their lifestyle. Therefore, the reviewer found that the requested 
neuropsychological testing is not considered to be reasonable or 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 neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96132).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick system (K1006). 
 
You asked the Plan to pre-approve a PureWick system. You say that the enrollee is at risk for skin breakdown. 
You also say that the requested item is medically necessary for the enrollee.  The Plan denied your request. The 
Plan says the requested item is experimental and investigational and therefore is not covered.  
 
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 PureWick system. Our reviewer says that the requested Purewick system is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the requested item is considered experimental and investigational and therefore is not 
medically reasonable or 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 PureWick system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a PureWick system (K1006).