Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a destruction by neurolytic agent; other peripheral nerve 
or branch (64690). 
 
You asked the Plan to pre-approve a peripheral nerve block. You say that your provider feels that this is the 
best option for treatment of your pain. The Plan denied your request. The Plan says the requested injection is 
considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a peripheral nerve block. Our reviewer 
says that the requested peripheral nerve block is not considered medically reasonable and necessary in this 
case.  Our physician reviewer found peripheral nerve injections of this type are considered experimental 
/investigational for shoulder pain, and effectiveness has not been established. Therefore, the reviewer found that the requested injection 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 peripheral nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a destruction by neurolytic agent; other peripheral nerve or branch (64690).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat medial branch blocks (MBBs) (64490, 64491). 
 
You asked the Plan to pre-approve repeat MBBs. You say that the enrollee needs the injection to improve their 
condition. The Plan denied your request. The Plan says the requested MBBs are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 repeat MBBs. Our reviewer says that 
repeat medial branch blocks are not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the relief that the enrollee received from the first medial branch blocks 
(MBBs). The reviewer also found that the records do not report specific imaging findings that document a 
degenerative condition that affects her spine (facet arthropathy) or the physical exam findings that support the diagnosis. Therefore, the reviewer found that the request for repeat MBBs 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 repeat MBBs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat medial branch blocks (MBBs) (64490, 64491).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (81291, 81335, 81227, 81230, 81328, 81231, 
81355, 81232, 81408, 81240, 81241) provided on November 1, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab testing have not been met. 
Therefore, we decided that the Plan does not have to pay for lab testing (81291, 81335, 81227, 81230, 81328, 
81231, 81355, 81232, 81408, 81240, 81241) provided on November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dual mode battery charger (E2367). 
 
You asked the Plan to pre-approve a dual mode battery charger. You say that you have a dual power 
wheelchair, and a single battery does not work on your wheelchair. You also say that the dual mode battery 
charges two batteries at a time, and the single mode battery charger messes up your wheelchair. The Plan 
denied your request. The Plan says a dual mode battery charger is not deemed reasonable and necessary by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a single mode battery charger (E2366) is 
appropriate for charging a sealed lead acid battery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a dual mode battery charger have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a dual mode battery charger (E2367).
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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lumbar spine surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical 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. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 pre-approve physician's services to be provided by an out-of-network 
glaucoma specialist. 
 
You asked the Plan to pre-approve physician's services to be provided by an out-of-network glaucoma 
specialist. You say that you do not believe that any other glaucoma specialist can take care of this patient like 
this provider can. The Plan denied your request. The Plan says the enrollee must receive your care from an  
in-network provider when available. In most cases, care received from an out-of-network provider will not be 
covered, exceptions include the following: 
-Urgent or Emergent Services 
-In-Network providers unable to provide the service required 
-Kidney Dialysis while out of your service area. 
 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by an out-of-network glaucoma specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the requested power wheelchair and 
accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee 
does have a mobility dysfunction that appears to impair MRADLs in the home. The documentation is 
conflicting. The medical records note that the enrollee has impaired sensation from the waist to feet and has 
paraplegia, however the physician evaluation on exam indicates normal sensation. The 4/5 upper extremity 
strength in the physicians documentation should be sufficient to perform pressure relief. There is no evidence 
of spasticity, being at high risk for pressure ulcer, or using intermittent catheterization. The requested Group 3 
power wheelchair with multiple power options and accessories appear to exceed the enrollee's needs.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from September 4, 2022, through October 6, 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 the services are not supported without the required documentation. 
 
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 "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided documentation 
describes that the enrollee was admitted for psychosis but was in no acute distress. The examination findings 
were detailed, but generally unremarkable. The enrollee was deemed medically stable and cleared for 
behavioral health treatment. The other notes describe a refusal for labs, tolerating regular diet, with stable vitals 
and the enrollee being generally asymptomatic. The documentation did not clearly support a detailed interval 
history or medical decision making of high complexity to justify CPT 99233. 
 
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 subsequent hospital care (procedure code 99233) rendered from September 4, 2022, through 
October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 4, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 4, 2022 to 
April 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 4, 2022 to April 
2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need skilled therapy because you could fall if 
you return home. The Plan denied your request. The Plan says the SNF services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87631, 99072) provided on September 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Additionally, code 99072 has a status indicator of "B". Payment is always bundled with another 
service. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (87631, 99072) provided on 
September 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (code E2300) and a 
power standing feature (E2301).  
 
You asked the Plan to pre-approve a power seat elevation feature (code E2300) and a power standing feature 
(E2301). You say that these items are medically necessary for you to have on your power wheelchair. The Plan 
denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature.  This means 
that these items cannot be covered, regardless of appropriateness or medical necessity. Therefore, we decided 
that the Plan does not have to pre-approve a power seat elevation feature (code E2300) and a power standing 
feature (E2301).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy (EBT) to be provided in 10 
fractions. 
 
You asked the Plan to pre-approve the 10 fractions of EBT. You say that the enrollee has skin cancer in 
multiple locations and the longer that is taken, the more the cancer can spread.  The Plan denied your request. 
The Plan says research studies have found a lack of proof that routine use of the requested type of treatment 
would improve the outcome for the enrollee's type of cancer. The Plan says that it has not been shown that the 
enrollee's cancer type has responded well to the requested type of treatment. 
 
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 10 fractions of EBT. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our physician reviewer found the most recent National Comprehensive Cancer Network (NCCN) guidelines for 
basal cell and squamous cell skin cancers explicitly state There are insufficient long-term efficacy and safety 
data to support routine use of electronic surface brachytherapy". Many other studies indicate that surgical 
management is the most effective treatment providing the highest cure rate and that electronic brachytherapy or 
superficial radiation can be considered for special circumstances in which surgical resection is 
contraindicated. It also states that long-term outcomes are needed to for electronic brachytherapy and 
superficial radiation. Overall, the literature is not supportive of the use of EBT over standard approaches of 
radiation delivery. 
 
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 10 fractions of EBT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy (EBT) to be provided in 10 fractions.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing this denial. The 
Plan denied your request. The Plan says that the enrollee does not meet criteria for a continuous glucose 
monitor. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit medical records related to this request. We requested 
medical records, but the correct medical records were not submitted to us. Therefore, the Plan has not shown 
that its decision to deny authorization for a CGM is medically correct or justified according to Medicare rules. 
Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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 the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the enrollee has tried and failed various 
conventional disease modifying therapies that are FDA approved for multiple sclerosis. The Plan denied your 
request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective to 
treat back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. More studies are needed to show Vertiflex is safe and effective. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.