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

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty. 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that the enrollee has been experiencing 
arthritic pain that has been worsening for the last 3 years. You say that the enrollee has tried and failed 
conservative treatments including chiropractic, physical therapy, and over the counter medications. You also 
say that this service would be beneficial for the enrollee and their quality of life. The Plan denied your request. 
The Plan says the documentation does not indicate that the enrollee has tried and failed conservative 
treatments. The Plan also says this 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 a total hip arthroplasty. Our reviewer 
says that the requested total hip arthroplasty is not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. There is no clear documentation of any 
recent prescription medications, or any injection therapy having been trialed. Moreover, the x-rays were noted 
on the exam without any formal diagnostic studies. Therefore, the requested total hip arthroplasty 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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve extracorporeal shock wave therapy (OssaTron). 
 
You asked the Plan to pre-approve OssaTron therapy. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve OssaTron therapy. Our reviewer says 
that the requested OssaTron therapy is considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates the enrollee is noted to have relief of the arch 
pain with physical therapy, although the heel pain persists. The enrollee has tried and failed medications, 
custom inserts, and physical therapy. The updated, current peer-reviewed literature supports extracorporeal 
shockwave therapy as a safe and effective treatment for chronic plantar fasciitis. Therefore, requested 
extracorporeal shock wave therapy (OssaTron) is 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 OssaTron therapy have been met. Therefore, we decided that the Plan has to 
pre-approve extracorporeal shock wave therapy (OssaTron).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a T12 vertebroplasty (22510) and inpatient admission. 
 
You asked the Plan to pre-approve a T12 vertebroplasty. You say that the enrollee has failed conservative 
treatment. You say that the enrollee continues to have a significant amount of pain. You also say that a 
vertebroplasty is medically necessary. The Plan denied your request. The Plan says this procedure is not 
medically necessary. The Plan also says there is no evidence to support the expectation the enrollee will require 
a greater than 2 midnight stay. 
 
The Plan follows Medicare rules. Medicare rules say that retropulsion fracture is a contraindication for 
percutaneous vertebroplasty or vertebral augmentation. 
 
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 T12 vertebroplasty. Our reviewer says 
that the requested T12 vertebroplasty is not medically necessary. Our physician reviewer found the magnetic 
resonance imaging (MRI) from June 2023 had findings including burst fracture of T12 with retropulsion of 
bone fragments into the ventral epidural space. This is further corroborated by the computed tomography (CT) 
scan from June 2023 which showed acute compression fracture of the T12 vertebral body with 4 to 5 
millimeters (mm) of osseous retropulsion into the spinal canal. Therefore, the documentation does 
support/evidence a retropulsion of fracture. The guidelines support that retropulsion fracture is a contraindication for vertebroplasty. Therefore, the reviewer found that the requested T12 vertebroplasty and 
associated inpatient admission 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 T12 vertebroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a T12 vertebroplasty (22510) and inpatient admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroplasty and/or transposition; median nerve at carpal 
tunnel (64721). 
 
You asked the Plan to pre-approve the surgical service. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is no documented trial of splinting. The Plan also 
says that more conservative measures are needed. 
 
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 surgical service. Our reviewer says 
that the requested surgical service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not evidence therapy, splinting (including nocturnal), and/or 
injections for the left. The recent examination does not clearly document nocturnal symptoms with pain that wakes the enrollee from sleep. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. The reviewer found there was no compelling rationale 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested neuroplasty and/or transposition of the median nerve at the carpal tunnel 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve neuroplasty and/or transposition; median nerve at carpal tunnel (64721).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve referral to an out-of-network gastroenterologist. 
 
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 available from network providers. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
referral to an out-of-network gastroenterologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous insulin therapy billed for date of 
service April 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the charges. The 
Plan denied your request. The Plan says the services are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that providers must report services correctly. 
 
We looked at the file, and Medicare rules. Intravenous insulin therapy is not covered in an outpatient setting. 
The records show that the refill and maintenance of a portable pump was ordered, but the records do not show 
the services were provided. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient 
intravenous insulin therapy billed for date of service April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on January 6, 2023. 
 
You asked the Plan to pay for CxBladder testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no coverage for CPT codes 0012M and 
0013M for CxBladder.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare coverage rules 
have not been met. Specifically, the service at issue is explicitly non-covered. Therefore, we decided that the 
Plan does not have to pay for CxBladder testing (0013M) provided on January 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient psychiatric admission provided January 16, 
2023, to January 25, 2023. 
 
You asked the Plan to pay for an inpatient psychiatric admission. You say that the entire length of stay was 
medically necessary for the enrollee.  The Plan denied your request. The Plan says this admission was not 
medically necessary. 
 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 an inpatient psychiatric admission. Our 
reviewer says that this admission was not medically necessary. Our physician reviewer found the beneficiary is 
chronically impaired due to major neurocognitive disorder and the continued inpatient hospital stay beyond 
1/20/2023 was not expected to improve the beneficiarys condition in a reasonable period of 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 an inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pay for an inpatient psychiatric admission provided January 16, 2023, to January 
25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 19, 2022, to 
July 21, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the required services could have been provided at an 
observation level of care. 
 
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 evaluation noted the enrollee was extubated in the ED, was quickly stabilized and 
was started on buprenorphine by hospital day two.  There was no indication from the documentation that at the 
time of admission inpatient care would have likely crossed two midnights. Observation status would have 
sufficed for this enrollee's treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided July 19, 2022, to July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81479). 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 gene testing. You say that you have many family 
members with a history of cancer who have tested positive for these genes, and feel it is important to know for 
your own care. The Plan denied your request. The Plan says this service is not covered when it is provided as a 
screening for an enrollee with no personal history of cancer. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, BRCA1 and BRCA2 gene testing, is being requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pre-approve BRCA1 and BRCA2 genetic testing (81479).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the endovenous radiofrequency ablation (ERFA) of left great 
saphenous vein (GSV) (36475) provided on December 19, 2022. 
 
You asked the Plan to pay for the ERFA. You say that this service was approved. You say that the enrollee met 
the requirements for both of the requested procedures. You also say that this should be covered. The Plan 
denied your request. The Plan says that the ERFA is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation may be covered if all the 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 pay for the ERFA. Our reviewer says that the 
requested ERFA is medically necessary. Our physician reviewer found There is satisfactory documentation of 
significant symptoms attributable to the varicose veins in question resistant to conservative efforts.  There is 
satisfactory documentation of absence of vein aneurysm or significant peripheral artery disease.  There is 
satisfactory documentation the portion of GSV treated has significant reflux and was free of significant 
tortuosity or thrombus. As the portion of the GSV treated has no thrombus, there would be no reason to deny 
approval based on thrombus in the untreated portions of the vein. Therefore, the reviewer found that the ERFA 
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 the ERFA have been met. Therefore, we decided that the Plan has to pay for the 
endovenous radiofrequency ablation (ERFA) of left great saphenous vein (GSV) (36475) provided on 
December 19, 2022.   
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the requested service is not medically necessary.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the Plan. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 27, 2022, to 
June 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 The Plan follows Medicare rules. The rules say that certain data elements are required. 
 
We looked at the claim submitted, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, we find that 
the first Q code line and first G code line were not billed with the same date of service. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from May 27, 2022, to June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physical therapy treatment table. 
 
You asked the Plan to pre-approve a physical therapy treatment table. The Plan denied your request. The Plan 
says this item is not generally used primarily for health care. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a physical therapy treatment table.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 12, 2022, billed 
with evaluation and management (EM) code 99223. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the level of care. 
 
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, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation did not support a 
comprehensive physical or high complexity decision-making, but rather moderate complexity decision-making, 
and therefore, the 99223 code is not sufficiently supported for this encounter.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on November 12, 2022, billed with evaluation 
and management (EM) code 99223.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96413 billed for January 10, 2023. 
 
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 procedure code 96413 is 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. 
 
In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. 
 
We find that CPT code 96413 is not supported in the medical record. Specifically, the records show the 
enrollee underwent an infusion of Entyvio and there is a more appropriate code for these services. 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 procedure code 96413 billed for January 10, 2023.