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

 
We decided that the Plan does not have to pre-approve percutaneous minimally invasive fusion/stabilization of 
the sacroiliac join for the treatment of back pain. 
 
You asked the Plan to pre-approve percutaneous minimally invasive fusion/stabilization of the sacroiliac join 
for the treatment of back pain. You say that it is medically necessary. The Plan denied your request. The Plan 
says it is not medically necessary. 
 
The Plan follows 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 percutaneous minimally invasive 
fusion/stabilization of the sacroiliac join for the treatment of back pain. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the MRI of the lumbar spine does corroborate neural 
compression that could be the source of the pain. Therefore, the enrollee does meet limitations/exclusions for 
this request. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous minimally invasive fusion/stabilization of the sacroiliac join for 
the treatment of back pain have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous minimally invasive fusion/stabilization of the sacroiliac join for the treatment of back pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that using a regular wheelchair is causing 
medical issues. The Plan denied your request. The Plan says the wheelchair is not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair is only covered under 
certain medical indications. The file does not show that you have a mobility limitation that is due to a 
neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does 
not have to pre-approve a group 3 power wheelchair.
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 currently in the hospital and it is 
not safe to be discharged home yet. The Plan denied your request. The Plan says based on Medicare guidelines, 
the LTACH services you 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 record indicates that you are improving but still require acute care services before 
transitioning to a lower level of care. You continue to receive acute care services and these have not been 
denied.  The medical record does not indicate that you require services that you are not currently receiving but that 
would be available at the LTACH facility. The elements of coverage are not satisfied. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of hyperbaric oxygen therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has dental caries and requires dental work to be performed. the record provided does 
not document the presence of an enumerated condition for which coverage is available under the rules. The 
elements of the coverage criteria are not satisfied. The requested service is not 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 HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of hyperbaric oxygen therapy (99183).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is the most 
appropriate for the enrollee to achieve the best outcome due to their complex medical needs. The Plan denied 
your request. The Plan says an LTACH admission 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 that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 27, 2022, billed 
with codes 27606, 20694, and 11044. 
 
You asked the Plan to pay for the medical services as billed. You say that these services were billed correctly 
and should be paid.  The Plan denied your request. The Plan says the services as 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. 
 
In this case, the CPT Code Manual definition of code 27606 is tenotomy, percutaneous, Achilles tendon 
(separate procedure); general anesthesia. The definition for code 20694 is removal, under anesthesia, of 
external fixation system.  
 
We have confirmed that code 11044 is a Column 2 code in relation to Column 1 code 27606; however, this 
code was billed with modifier -79. 
 
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 medical services as billed. Our reviewer says that the 
operative report does not support the services billed.  Our reviewer found for code 27606, the provider incises 
the Achilles tendon percutaneously, and this service was not documented in the report. For code 20694, a 
postoperative procedure for removal, under anesthesia, of external fixation system was not found in medical 
record submitted. Lastly, for 11044, the procedure report describes debridement performed right foot, same 
anatomical area as the primary procedure performed. However, in this case, this procedure would be included 
in the more comprehensive procedure. 
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on October 27, 2022, billed with codes 27606, 
20694, and 11044.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiotherapy (PBRT) for prostate cancer 
treatment.  
 
You asked the Plan to pre-approve the requested PBRT. You say that the treatment is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the National Comprehensive Cancer Network 
(NCCN) guidelines for prostate cancer states that treatment for metastatic prostate cancer is recommended to 
be androgen deprivation therapy with external beam radiation therapy to the primary tumor for low metastatic 
burden and to distant metastases. A review of the literature indicates that PBRT is not the standard of care for 
prostate cancer and Proton Beam therapy for primary treatment of prostate cancer should only be performed 
within the context of clinical trial. 
 
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 requested PBRT. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found National Comprehensive Cancer Network (NCCN) guidelines recommend androgen 
deprivation therapy with external beam radiation therapy to the primary tumor for low metastatic burden and to 
distant metastases. Other guidelines recommend PBRT only when provided within an approved clinical trial. 
This enrollee is not in a clinical trial. 
 
The dose volume histogram (DVH) for this enrollee was reviewed, and there is no level I evidence showing 
that PBRT would provide a superior outcome compared to intensity-modulated radiotherapy (IMRT) with 
volumetric modulated arc therapy (VMAT). Based on the information provided, IMRT/VMAT can be safe and 
effective, meaning that PBRT exceeds the enrollee's medical need in this case.  
 
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 requested PBRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiotherapy (PBRT) for prostate cancer treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an enclosed four-sided framed walker coded as E0144. 
 
You asked the Plan to pre-approve an enclosed walker. No specific argument was provided with your appeal 
request. The Plan denied your request. The Plan says the requested walker with an enclosed frame is not 
eligible for coverage under Medicare rules. The Plan must follow Medicare rules. Medicare rules say that 
enclosed walkers are not covered. The specific walker being requested is an enclosed walker. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an enclosed walker have not been met. Therefore, we decided that the Plan does not have to pre-
approve an enclosed four-sided framed walker coded as E0144.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that it is medically necessary. The Plan denied your 
request. The Plan says this provider is out-of-network, and the services could be performed in-network. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a sacroiliac joint 
injection 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 the injection. Our reviewer says that a 
sacroiliac joint injection is not medically necessary. Our physician reviewer found that the LCD requires at 
least 50% pain relief or 50% consistent improvement in the ability to perform previously painful movement 
and activities of daily living for at least three months from the proximate therapeutic injection, which was not 
achieved. Therefore, the request is 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the system monitors symptoms that 
lead to repeat hospitalizations. The Plan denied your request. The Plan says there is not enough evidence the 
device would improve the outcome 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 the requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). Follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight Psychotropic testing provided on April 27, 
2023, billed with code 0345U-GY. 
 
You asked the Plan to pay for the Genesight Psychotropic testing as billed. You say that this is a medically 
necessary test that is covered by Medicare. The Plan denied your request. The Plan says this claim cannot be 
paid as it was billed with modifier -GY.  
 
The Plan must follow Medicare rules. Medicare rules say that claim lines billed with modifier -GY are 
statutorily excluded from coverage.  
 
 
 Though the provider argues this is a covered test, it was billed with a modifier indicating it is statutorily 
excluded from coverage. This means it cannot be paid as billed. Therefore, we decided that the Plan does not 
have to pay for the Genesight Psychotropic testing provided on April 27, 2023, billed with code 0345U-GY.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the OON services. You say that the enrollee spends a portion of the year in 
Florida. The Plan denied your request. The Plan says there are network providers available. 
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. The requested provider is not a network provider with the Plan. The 
Plan has network providers available for the services requested. The medical records show the enrollee was last 
seen by the requested provider in 2019. The documentation does not show why the requested services are 
needed from an out-of-network provider. Based on this information, we decided that Medicare rules for 
coverage not been met. Therefore, we decided that the Plan does not have to pre-approve orthopedic services to 
be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator (64555). 
 
You asked the Plan to pre-approve a peripheral nerve stimulator. 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 no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a peripheral nerve stimulator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the peripheral nerve stimulator at issue in this case meets all 
Medicare/NCD criteria for medically reasonable and necessary and safe and effective for the enrollee. Provided 
records in this case do not document the enrollee has undergone careful screening, evaluation and diagnosis by 
a multidisciplinary team prior to implantation including a psychological evaluation. 
 
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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in an average volume assured pressure support (AVAPS) mode which is a 
modality that could be provided by a bilevel positive airway pressure (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. 
 
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 (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right/left lower extremity revascularization procedures 
(37225 and 37226). 
 
You asked the Plan to pre-approve right/left lower extremity revascularization procedures. 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 PTA is covered when used under certain conditions. 
 
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 right/left lower extremity 
revascularization procedures. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not 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 right/left lower extremity revascularization procedures have not been met. 
Therefore, we decided that the Plan does not have to pre-approve right/left lower extremity revascularization 
procedures (37225 and 37226).