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

 
We decided that the Plan does not have to pre-approve the radiofrequency generated water vapor 
thermotherapy (53854).  
 
You asked the Plan to pre-approve the radiofrequency generated water vapor thermotherapy . You say that the 
service is medically necessary. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that water vapor thermal therapy for the treatment of 
lower urinary tract symptoms attributable to benign prostatic hyperplasia (LUTS/BPH) are covered once in 
patients with both criteria listed in 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 the radiofrequency generated water 
vapor thermotherapy. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the International Prostate Symptom Score (IPSS) is not greater than or equal to 13 and the enrollee is not 
a poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease, 
pulmonary disease, etc.), or at high risk of bleeding. 
 
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 radiofrequency generated water vapor thermotherapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the radiofrequency generated water vapor 
thermotherapy (53854).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that after your stroke you require IRF services. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an angiogram with revascularization procedure. 
 
You asked the Plan to pre-approve an angiogram with revascularization. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 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 an angiogram with revascularization. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found that, as you acknowledge, the enrollee's symptoms are more consistent 
with known lumbar spine disease. The findings on the pulse examination do not explain the pain radiating 
down the enrollee's entire leg including the groin. There is a plan for invasive imaging and possible 
intervention without the support of more objective noninvasive studies. The need for more objective data is 
rendered even more important as there is a higher likelihood than average that the enrollee will not experience 
meaningful improvement in quality of life following arterial intervention and there is no evidence of limb 
threat. 
 
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 angiogram with revascularization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an angiogram with revascularization procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for the billed service. You say that the place of service is valid and payable.  The 
Plan denied your request. The Plan says the place of service is not valid for the procedure code. 
 
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 99212 is office or other outpatient visit for the evaluation 
and management of an established patient. We find that CPT code 99212 is not supported. CPT code 99212 is an outpatient code. The claim was billed 
with an inpatient place of service code. There is a more appropriate procedure code available to describe 
inpatient evaluation and management services. Based on this information, we decided that Medicare rules for 
coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99212 billed for date of service May 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the pathology services provided on June 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records show the services were 
provided.   The Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The Plan has not provided a claim, explanation, or 
any other documentation showing the services were previously billed. Based on this information, we decided 
that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the Plan has 
to pay for the pathology services provided on June 17, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on November 10, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgery 
services are not payable for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 22513. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met.  Therefore, we decided that the Plan does not have to pay for the assistant surgery 
services provided on November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found products classified as HCPCS code E0466, when used to provide continuous positive airway pressure (CPAP) or bi-level positive airway pressure (PAP 
(with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the 
FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in this 
RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP 
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions 
described in the Medicare RAD policy will be denied as not 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission based on medical necessity. The Plan denied your request. The Plan says the 
IRF services requested do not meet the requirements for approval.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multilevel kyphoplasty procedure. 
 
You asked the Plan to pre-approve a multilevel kyphoplasty procedure. You say that the records provided 
support the need for the service in dispute. You say that Medicare guidelines for coverage of this treatment 
have been met.  The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
coverage.  
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty procedures are covered for certain 
indications and when medically reasonable and 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 a multilevel kyphoplasty procedure. 
Our reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the enrollee 
does not have painful, debilitating, osteoporotic vertebral collapse/compression fractures that have not 
responded to non-surgical medical management with and without methods of immobility. The enrollee does not 
have acute or subacute osteoporotic Vertebral Compression Fracture (VCF) based on symptom onset and 
documented by advanced imaging demonstrating bone marrow edema on magnetic resonance imaging (MRI) 
or bone-scan/Single-photon emission computed tomography (SPECT)/computed tomography (CT) uptake. The 
enrollee is not symptomatic and hospitalized with severe pain, nor is the enrollee non-hospitalized with 
moderate to severe pain despite optimal non-surgical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a multilevel kyphoplasty procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a multilevel kyphoplasty procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on October 12, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that physical therapy has greatly improved the 
enrollee's physical and emotional state. You say that the enrollee came to their first appointment in a 
wheelchair and is now out and walking. The Plan denied your request. The Plan says physical therapy is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our reviewer says 
that skilled services were not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that while there is little functional gain 6 months after a 
stroke the enrollee can continue with a repetitive exercise program. The physical therapy has been effective for 
the enrollee but additional recovery rests on a neurological recovery. Additionally, a neurological recovery is 
not expected and functional may occur with continued exercises. Therefore, continued input from a skilled 
therapist is not medically necessary for their condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on October 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Soliris. 
 
You asked the Plan to pre-approve Soliris. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Soliris. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the information received the Plan 
denied the request, citing the Soliris is not being prescribed for an FDA labeled or medically accepted use, cold 
agglutinin chronic hemolytic anemia Its use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Soliris have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Soliris.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's provider indicates that they 
require noninvasive ventilator therapy over BiPAP to reduce respiratory distress and anticipated pulmonary 
decline. The Plan denied your request. The Plan says the requested ventilator is 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 a home ventilator. Our reviewer says that the requested home ventilator is not medically necessary. Our physician reviewer found the provided 
records indicate a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
The reviewer found that provided records indicate that the home ventilator is being requested for use in average 
volume assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP 
device with AVAPS and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. Therefore, the reviewer found that the requested ventilator 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic blood pressure monitor (A4670) purchased on 
August 29, 2022. 
 
You asked the Plan to pay for the automatic blood pressure monitor. The Plan denied your request. The Plan 
says you do not meet the Medicare guidelines for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension. 
 
 
 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 automatic blood pressure monitor. Our 
reviewer says that you do not meet the coverage criteria for the automatic blood pressure monitor. Our 
physician reviewer found you were evaluated by your physician on December 15, 2022, who noted your blood 
pressure was satisfactory (130/60). The review has determined that you do not have suspected white coat 
hypertension. Our reviewer found that you do not have suspected masked hypertension. Our physician reviewer 
also found that you do not meet the NCD criteria for coverage. 
 
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 automatic blood pressure monitor have not been met. Therefore, we decided 
that the Plan does not have to pay for the automatic blood pressure monitor (A4670) purchased on August 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid treatment program (OTP) services provided on 
January 9, 2023. 
 
You asked the Plan to pay for the OTP services. The Plan denied your request. The Plan says this provider is 
not payable for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities.  
 
We looked at the file and Medicare rules. The services in this case were provided and billed by an individual 
provider. Individual providers are not eligible to bill for OTP services. Based on this information, we decided 
that Medicare rules for coverage of the OTP services have not been met. Therefore, we decided that the Plan 
does not have to pay for the opioid treatment program (OTP) services provided on January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Avise CTD test (0312U) provided May 20, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please see the attached documents and below 
information regarding the test hat was deemed medically necessary by the enrollee's physician. The Plan denied 
your request. The Plan says this service does not meet the medically necessary criteria for coverage. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our physician reviewer found per the literature, the AVISE connective tissue disease (CTD) test has been 
demonstrated to aid in differentiation of systemic lupus erythematosus (SLE) diagnosis from other CTDs and 
FM. There was a study to evaluate its clinical utility in a real-world cohort. Patients with a positive AVISE test 
who did not have a confirmed diagnosis at baseline were more likely to develop a firm SLE diagnosis within 2 
years after testing. The AVISE test demonstrated high specificity and good sensitivity for predicting the 
development of SLE at 2 years and was the only biomarker in multivariate analysis to be associated with a 
diagnosis of SLE at 2 years. Interestingly, positive patients were also more likely to develop damage at baseline 
and 2 years. Furthermore, patients with damage had significantly greater levels of B cell bound split C4 
complement component (BC4d) at both baseline and 2 years than those without. Taken together, these results 
suggest that AVISE positivity is predictive of SLE diagnosis and damage progression. In this case the enrollee 
does not have a diagnosis of SLE or a specific CTD. The review has determined that the items/services at issue 
in this case are 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the Avise CTD test (0312U) provided May 20, 2022.