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

 
We decided that the Plan does not have 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 
when two power seating functions/actuators/motors are provided, one unit of E2311 is allowed. You also say 
that the expandable controller and harness are not an integral part of the base, thus a split decision should be 
possible. The Plan denied your request. The Plan says these items cannot be covered as it is not medically 
necessary to control the three requested power options through the joystick (drive interface). 
 
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, and 
expandable controller. 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 paraplegia but is able to 
support themself and walk with forearm crutches, albeit unsteadily. Our reviewer also found that the enrollee 
has adequate upper body strength to manage standard power drives. 
 
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 not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on January 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that the records do not support the billed HIPPS code. 
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 pay for the home health services rendered on January 14, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PVA at T7 (22513).  
 
You asked the Plan to pre-approve a PVA. You say that without surgical intervention, the healing may occur 
incorrectly and cause more pain for the enrollee. The Plan denied your request. The Plan says this procedure is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PVA is covered when all the criteria listed in the 
Medicare rules section 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 a PVA. Our reviewer says that this 
procedure is not medically necessary. Our physician reviewer found that there is no trial of fracture bracing. 
More conservative measures are 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 a PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a PVA at T7 (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are not enough studies on Vertiflex Superion 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 the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion, including any associated procedures, 
implants or supplemental bone products, unspecified instrumentation, unspecified allograft and hospital 
inpatient admission (22558, 22853, 22585, 20930). 
 
You asked the Plan to pre-approve lumbar fusion, including any associated procedures, implants or 
supplemental bone products, unspecified instrumentation, unspecified allograft and hospital inpatient 
admission. 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 lumbar fusion, including any associated 
procedures, implants or supplemental bone products, unspecified instrumentation, unspecified allograft and 
hospital inpatient admission. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documentation of 6 weeks of 
physical therapy for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion, including any associated procedures, implants or supplemental 
bone products, unspecified instrumentation, unspecified allograft and hospital inpatient admission have not 
been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion, including any 
associated procedures, implants or supplemental bone products, unspecified instrumentation, unspecified 
allograft and hospital inpatient admission (22558, 22853, 22585, 20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service October 16, 
2022. 
 You asked the Plan to pay for procedure code 87640. The Plan denied your request. The Plan says payment for 
code 87640 is bundled into payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 87640 billed for date of 
service October 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty (22510).  

You asked the Plan to pre-approve vertebroplasty. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 vertebroplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, greater than 25% 
vertebral body height loss, or kyphotic deformity. Moreover, there is magnetic resonance imaging (MRI) 
corroboration of retropulsion. Therefore, the enrollee does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebroplasty (22510).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you have had significant relief from 
radiofrequency ablation treatments in the past. You say these treatments no longer provide significant relief. 
You also say that you believe this is your best chance at attaining a life free from chronic pain and its 
debilitating consequences. The Plan denied your request. The Plan says this service is considered experimental 
and investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates vertbrogenic back pain but also indicates 
lumbar degenerative disc disease, facet arthropathy and lumbar radiculopathy which may be the source of your 
pain. The documentation does not indicate that a multidisciplinary team has evaluated your pain. These factors 
are not supportive that the Intracept procedure meets the requirements of the generally accepted standards of 
care. Therefore, the reviewer found that the requested procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block provided on September 28, 2022. 
 
You asked the Plan to pay for the nerve block. You say that this meets medical necessity per the guidelines in 
Article A57452. You also say that this should be reprocessed and paid. The Plan denied your request. The Plan 
says this was 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 pay for the nerve block. Our reviewer says that the 
nerve block is not considered medically reasonable and necessary in this case. Our physician reviewer found the role of genicular nerve blocks and of radiofrequency ablation (RFA) of the genicular nerves is the subject 
of ongoing clinical trials.  It is considered experimental/ investigational therapy at this time.  Therefore, the 
nerve block was 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pay for the genicular nerve block provided on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you cannot walk at all and needs this due to 
having shortness of breath. You also say that you are house bound due to not able to get around on your own. 
The Plan denied your request. The Plan says this request is not medically necessary because the records do not 
show that you have the mental and physical capabilities to safely operate the requested device. The Plan also 
says that the records do not show that you have enough room in your home for use of the requested scooter, or 
that you are able to maintain upright posture while seated and safely use a scooter. 
 
 
 
 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 power scooter. Our reviewer says that 
a power scooter is not medically necessary for you. Our physician reviewer found you do not require a power 
operated vehicle to manage MRADLs in the home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, 96366, 96521, and J1817 for date of service 
March 23, 2023. 
 
You asked the Plan to pay for codes 96365, 96366, 96521, and J1817. 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 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the medical records indicate that outpatient intravenous insulin treatment (OIVIT) either pulsatile or 
continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or urine urea 
nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed.  
 This means there is a more appropriate code that should be billed; therefore, codes 96365 and 96521 are not 
supported. While the documentation includes an order to perform refilling and maintenance or portable pump, 
the records do not include a procedure report for pump maintenance refill. Therefore, code 96521 is not 
supported. The documentation shows that Nova R was administered via intravenous treatment. There is a more 
appropriate code to be billed; therefore, code J1815 is not supported. 
 
Based on this information, we decided that Medicare rules for coverage of codes 96365, 96366, 96521, and 
J1817 have not been met. Therefore, we decided that the Plan does not have to pay for codes 96365, 96366, 
96521, and J1817 for date of service March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you are aware that you do 
not have diabetes or kidney disease, but you were referred by your endocrinologist and need help getting your 
blood sugar under control. The Plan denied your request. The Plan says there is no documentation or evidence 
of diabetes and no evidence of a reduction in renal function. The member does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 27, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must report an additional line item with the 
same revenue code and date of service, reporting one of the three Q codes (Q5001, Q5002, and Q5009), and a HIPPS code. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required HIPPS 
code or Q code. 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 pay for the home health services rendered 
from January 27, 2022, to January 31, 2022.
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 requires an IRF level of care. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria 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: 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 February 9, 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 
February 9, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 You asked the Plan to pre-approve Remicade. The Plan denied your request. The Plan says there has not been a 
trial of the preferred drugs.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Remicade. Our physician reviewer 
found that the enrollee has rheumatoid arthritis. The requested medication is a new start. The Plan requires a 
trial of Avsola or Inflectra before they will approve the requested drug. The records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative.  
The elements of the coverage criteria are not satisfied. 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 Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 9, 
2022. 
 You asked the Plan to pay for procedure code 87481. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87481 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 
is a column II code 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 code 87481 billed for date of service December 9, 
2022.