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

 
We decided that the Plan does not have to pre-approve a percutaneous vertebroplasty (bone biopsy included 
when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; 
cervicothoracic (22510), a percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral 
body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or 
lumbosacral vertebral body (22512) and a percutaneous vertebral augmentation, including cavity creation 
(fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 
vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic (22513). 
 
You asked the Plan to pre-approve vertebroplasty. You say that you are requesting reconsideration because you 
are not able to stand for more than 10 minutes at a time and you feel that the surgery will help with provide 
relief and a better quality of life. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show you do not have an acute/subacute compression fracture by advanced 
imaging. 
 
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 vertebroplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found per the LCD, there is no imaging showing you have an acute fracture that is less than six weeks 
old. You do not meet criteria for approval of this procedure. 
 
 
 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 a percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, 
unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic (22510), a percutaneous 
vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, 
inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (22512) and a 
percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included 
when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral 
cannulation, inclusive of all imaging guidance; thoracic (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) and segmental 
appliance described by codes E0676 and E0667. 
 
You asked the Plan to pre-approve these services. You say that you need the device to reduce pain and 
inflammation. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a pneumatic compression device (PCD) that provides 
intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is not 
covered.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0676. These services are not 
covered by Medicare. Given that the E0676 PCD is not covered, the segmental appliance described by code 
E0667 is also not covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (PCD) and segmental appliance described by codes E0676 and E0667.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an infraumbilical panniculectomy. 
 
You asked the Plan to pre-approve panniculectomy. You say that you lost a bunch of weight, and these 
surgeries are all medically necessary. The Plan denied your request. The Plan says the medical criteria for a 
panniculectomy 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 panniculectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has had weight loss from bariatric surgery. The record 
provided does not document the presence of chronic intertrigo refractory to conservative medical treatment, a 
pannus that hangs beneath the pubis, or the presence of functional impairment.  The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an infraumbilical panniculectomy.
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 were able to walk but now are incapable of 
standing and walking. The Plan denied your request. The Plan says criteria for admission to the acute IRF 
setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography, extremity, unilateral, radiological supervision 
and interpretation rendered on October 17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 75710 is considered inclusive to CPT 37229 and is not distinct and independent from these 
services. 
 
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 75710 is "Angiography, extremity, unilateral, 
radiological supervision and interpretation." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there is not any sufficient 
documentation to validate that CPT 75710 was performed as a distinct separate service. Therefore, it was not 
appropriate to use modifier -59 to unbundle this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for angiography, extremity, unilateral, radiological supervision and interpretation rendered on 
October 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110 and 97140 rendered on December 21, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no documentation supporting a therapeutic procedure or manual therapy techniques 
which were billed and remain denied. 
 
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 the denied codes is: 
 
CPT 97110: 
 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and 
endurance, range of motion and flexibility 
 
CPT 97140: 
 
Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or 
more regions, each 15 minutes 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does include 
any documentation of therapeutic procedures or manual therapy techniques. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 97110 and 97140 rendered on December 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable yet has strong 
criteria for LTACH admission and is ready to transition to that level of care for pulmonary and medical 
management as well as starting an aggressive rehabilitation to return home safely. The Plan denied your 
request. The Plan says the LTACH services requested do not meet the requirements for approval.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652), segmental pneumatic appliance for use with pneumatic compressor, trunk 
(E0656), and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compressor, full leg segmental pneumatic appliance, and 
segmental pneumatic appliance for the trunk. 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 a segmented, calibrated gradient pneumatic 
compression device (HCPCS code E0652) is only covered when the individual has unique characteristics 
which prevent them from receiving adequate satisfactory pneumatic compression treatment using a 
nonsegmented device along with a segmented appliance or compression device without manual control of the 
pressure in each chamber.  
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 pneumatic compressor, full leg 
segmental pneumatic appliance, and segmental pneumatic appliance for the trunk. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found per the coverage criteria detailed in 
L33829, the equipment is not medically necessary to treat chronic venous insufficiency. 
 
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 pneumatic compressor, full leg segmental pneumatic appliance, and segmental 
pneumatic appliance for the trunk have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compressor, segmental home model with calibrated gradient pressure (E0652), segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656), and segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
December 13, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were provided in 
good faith and were medically necessary. The Plan denied your request. The Plan says the services were not 
medically necessary. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve a panniculectomy. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says a panniculectomy is not medically necessary for the enrollee's 
condition. 
 
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 panniculectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record provided does not document the presence of chronic intertrigo refractory 
to at least three months conservative therapy or functional impairment. There is insufficient literature to 
support the safety and efficacy, as defined by Medicare rules, of the requested service. 
 
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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on  
December 8, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only 
for diabetes and renal disease. 
 
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 the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 18, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on January 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has not been shown to be 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is considered 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on January 09, 2023. 
 
You asked the Plan to pay for mental health services. You say that due to being in a nursing home, choosing an 
in-network provider wasnt an option. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for mental health services 
provided on January 09, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft (20930), osteotomy of spine (22214), and 
transpedicular approach with decompression of spinal cord (63056). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a previous multi-level fusion. There has only been eight weeks of pain, and no 
physical therapy documented. More time and conservative measures are needed prior to extensive revision 
surgery. There are no red flags for surgery.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve allograft (20930), osteotomy of spine (22214), and transpedicular approach with 
decompression of spinal cord (63056).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 21, 2022, to 
April 19, 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 21, 2022. The NOA was not received by the Plan until April 27, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from March 21, 2022, to April 19, 2022.