Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF 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 the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While enrollee may have a need for physical therapy 
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 the enrollee 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  periodontal scaling and root planing (D4341), osseous 
surgery (D4260, D4261), and drugs medicaments dispensed in the office for home use (D9630). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the periodontal scaling and root planing has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the periodontal scaling and root planing was exhausted on date of service February 16, 
2022. Osseous surgery and drugs medicaments dispensed in the office for home use are not covered benefits. 
Therefore, we decided that the Plan does not have to pre-approve  periodontal scaling and root planing 
(D4341), osseous surgery (D4260, D4261), and drugs medicaments dispensed in the office for home use 
(D9630).
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 and your doctors believe you need to have more 
intense rehab services. The Plan denied your request. The Plan says you do not meet the criteria for admission 
to an IRF. 
 
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 you do not require treatment by multiple therapies. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, low intensity ultrasound, 
noninvasive (E0760). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that you are requesting reconsideration 
for the denied services. The Plan denied your request. The Plan says the request is not medically necessary 
because the records show the enrollee does not have non-union of a fracture. 
 
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 osteogenesis stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided, there is no documentation that the 
osteogenesis stimulator at issue in this case meets all Medicare criteria for medically reasonable and necessary 
and safe and effective for the enrollee. Provided records in this case do not document a fracture. As stated in 
the Local Coverage Determination (LCD) Osteogenesis Stimulators L33796: "An ultrasonic osteogenesis 
stimulator is covered only if all of the following criteria are met, nonunion of a fracture documented by a 
minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, 
separated by a minimum of 90 days. The fracture is not of the skull or vertebrae; and the fracture is not tumor 
related. An ultrasonic osteogenesis stimulator will be denied as not medically necessary if any of the criteria 
above are not met." 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, low intensity ultrasound, noninvasive (E0760).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 2, 2023, to 
January 31, 2023. 
 You asked the Plan to pay for the home health services. You did not provide a specific argument with your 
appeal request. 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 January 2, 2023. The NOA was not received by the Plan until February 13, 
2023. 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 home health services provided 
from January 2, 2023, to January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
4, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that  your dentist needed the x-ray 
and you were unaware you had one on June 2, 2021. You also say that the previous dental office closed and the 
records were not transferred to the new office. The Plan denied your request. The Plan says your benefit for the 
panoramic radiographic image has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service October 27, 2022. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on May 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that this is medically 
necessary. The Plan denied your request. The Plan says a review of the current medical literature does not 
support this service to be reasonable and necessary. More medical research is needed to support this is safe and 
effective 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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental procedure. It is the 
subject of ongoing clinical trials to determine its role in the management of osteoarthritis of the knee.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder for a wheelchair (E1399). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested cup holder for a wheelchair is not covered as it is not used to 
treat a medical condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cup holder for a wheelchair (E1399).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the intraoral-periapical first radiographic image (D0220) provided on 
October 25, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says that your benefit for the service 
provided has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically, there is no evidence showing your benefit for the service provided was 
previously exhausted. Therefore, we decided that the Plan has to pay for the intraoral-periapical first 
radiographic image (D0220) provided on October 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service April 14, 
2023.   
You asked the Plan to pay for procedure code 64488. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 64488 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 64488 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64488 billed for date of service April 14, 2023.
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 item is medically necessary. The Plan 
denied your request. The Plan says the item 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. Claims for ventilators used to provide continuous positive airway pressure (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 home ventilator. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found the enrollee could be treated with a 
BiPAP machine with AVAPS capability and failure of such a device has not been documented. 
 
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 pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0705, E1007, E1012, E2359, E1028, 
E2300, E2311, E2313, E2377, E0955, and E2603). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that you need the wheelchair because you are unable to move your legs at all, and it takes you a long 
time to get out of the wheelchair that was loaned to you. You also say that you need to call someone for help to 
get you out of your current wheelchair, so you need a seat that raises you up to help you get a better stance to 
stand up. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple 
power options included with K0861 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with multiple power options (such as 
code K0861) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say if the PWC base is not covered, then related accessories will be denied. 
 
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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that you do not meet the criteria for coverage. Our 
physician reviewer found you have inclusion body myositis and progressive decline in function. Our reviewer 
also found that you do not have high risk for skin breakdown, use a catheter intermittently, have spasticity or 
require an alternative means of managing power drive 
 
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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E0705, E1007, 
E1012, E2359, E1028, E2300, E2311, E2313, E2377, E0955, and E2603).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L1 and L2 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says you do not meet evidence-based criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
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 L1 and L2 kyphoplasty. Our reviewer 
says that the you do not meet criteria for coverage. Our physician reviewer found there is no trial of fracture 
bracing. There is fracture retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 and L2 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous vertebral nerve. 
 
You asked the Plan to pre-approve thermal destruction of intraosseous vertebral nerve. You say that the 
enrollee tried and failed conservative treatment without relief. The Plan denied your request. The Plan says 
there are no medical records to show that this procedure works better than others. 
 
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 thermal destruction of intraosseous 
vertebral nerve. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found There is no M=magnetic resonance imaging (MRI) 
showing only modic changes without facet joint disease or foraminal stenosis. The cause of back pain is also 
not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of intraosseous vertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous vertebral 
nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring device and power supply billed for date of 
service February 11, 2023. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We find that the monitoring device, code A9279, is statutorily non-covered. We find that the power supply, 
code E1399 does not serve a purpose that is primarily medical in nature. Based on this information, we decided 
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to 
pay for the monitoring device and power supply billed for date of service February 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service January 11, 2023. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are covered. 
 
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 G0483 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not payable as billed. Specifically, the documentation shows that the 
diagnoses are osteoarthritis of knee, right shoulder pain, and back pain. The documentation shows that the 
enrollee's medications include oxycodone, gabapentin, and ibuprofen. The number of drug classes tested should 
reflect only those likely to be present based on the medical history, current clinical presentation, and the illicit 
drugs that are in common use. It is not necessary to routinely test for drug classes which are not used to treat 
the enrollee. Based on this information, we decided that Medicare rules for coverage of code G0483 have not 
been met. Therefore, we decided that the Plan does not have to pay for code G0483 for date of service January 
11, 2023.