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

We decided that the Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint.

You asked the Plan to pre-approve the radiofrequency ablation. You say that the burning pain the enrollee gets has now been relieved since the previous injection. The Plan denied your request. The Plan says the radiofrequency ablation 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 radiofrequency ablation. Our reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that the radiofrequency ablation is considered experimental. 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 
29, 2022.  
 
You asked the Plan to pay for procedure code 99233. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99233 is bundled into payment for code 
99222. 
 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, we have confirmed that code 99233 
is a column two code to column one code 99222 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and management of an established patient in 
an office to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve evaluation and management of an established patient in an office. You say 
that you are requesting reconsideration for the denied claim. 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 
evaluation and management of an established patient in an office to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided May 4, 2023.   
You asked the Plan to pay for the orthosis. You say that please see attached medical records. The Plan denied 
your request. The Plan says this service is not medically necessary. The enrollee was interviewed and denied 
requesting or needing a back brace.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not indicate the enrollee has had a new injury or any specific problems 
to the spine or related soft tissue. There is no indication that the enrollee has had any surgical procedure. There 
is no clear indication that the enrollee required a lumbar-sacral orthosis. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar sacral orthosis (L0650) provided May 4, 2023.
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 LTACH is the appropriate level of care 
and the enrollee is medically stable to be transferred at this time. The Plan denied your request. The Plan says 
criteria for admission to the LTACH have not been met. 
 
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. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, pontics, and retainer crowns (D2950, D6245, 
D6740) provided on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
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. 

The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for core buildup, pontics, and retainer crowns (D2950, D6245, D6740) provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the provider has opted out of Medicare as of January 1, 
2017. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatry and psychology services. 
 
You asked the Plan to pre-approve psychiatry and psychology services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says there is no documented need 
for the requested service. 
 
The Plan follows Medicare rules. Medicare rules say that services must be for the purpose of diagnostic study 
or reasonably be expected to improve the patient's condition. The treatment must, at a minimum, be designed to 
reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization and improve or 
maintain the patient's level of functioning. 
 
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 psychiatry and psychology services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does 
not meet the criteria for neuropsychological testing as the testing could be performed in the clinical interview 
according to the LCD and is therefore not considered to be medically necessary or reasonable. The enrollee has 
a history of complex partial seizures which have been under control for some time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatry and psychology services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve psychiatry and psychology services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 11, 2023, billed with 
procedure code 01922-AA-QS. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim has not been reported with an 
appropriate modifier. 
 The Plan must follow Medicare rules. Medicare rules say that payment is determined based on the base unit of 
the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of 
the multiple procedures.  
 
We looked at the file and Medicare rules. We have confirmed that the billed code has not been reported with an 
appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on May 11, 2023, billed with procedure code 01922-AA-QS.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Diagnostics urinary tract infection (UTI) panel 
provided on May 31, 2023. 
 
You asked the Plan to pay for the Altru Diagnostic UTI panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the request for specific infectious agents by nucleic 
acid amplification exceeds the enrollee's medical needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Altru Diagnostic UTI panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that a review of the medical literature in clinical practice guidelines, 
indicates that standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine 
culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large multiplex 
PCR urinary tract infection panel tests. Thus, this testing was 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 Altru Diagnostic UTI panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the Altru Diagnostics urinary tract infection (UTI) panel provided on May 31, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee (L5828, L5845, L5848, 
L5856). 
 
You asked the Plan to pre-approve a K3 microprocessor knee. 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 lower limb prostheses are 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 a K3 microprocessor knee. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not reveal objective in person physician progress notes that support that the enrollee requires a K3 knee. 
The CPO telehealth notes are electronically signed by a physician, but the documentation does not support that 
the physician evaluated the enrollee independently. There is no objective physician progress note supporting a 
K3 level of activity or why the enrollee requires a K3 microprocessor knee over a mechanical 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 a K3 microprocessor knee have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a K3 microprocessor knee (L5828, L5845, L5848, L5856).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
  You asked the Plan to pre-approve a home ventilator.. You say that the requested home ventilator is medically 
necessary for the enrollee due to the diagnosis of chronic obstructive pulmonary disease (COPD). The Plan 
denied your request. The Plan says a home ventilator is not medically necessary for this patient because their 
needs can be met with an alternative device such as a BiPAP device with average volume-assured pressure 
support (AVAPS). 
 
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 home ventilator. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found that the record indicates the enrollee has 
chronic respiratory failure from COPD. The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine with AVAPS capability and failure of such a device has not been documented. Furthermore, 
Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy 
requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway 
pressure, regardless of the illness treated by the device. The elements of the coverage criteria 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 a home ventilator. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator (64561, 95971, 95972, 51715). 
 
You asked the Plan to pre-approve a sacral 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 sacral nerve stimulation is covered for the treatment 
of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. 
 
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 sacral nerve stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not meet the 
coverage criteria detailed in the NCD. Enrollees with stress incontinence are excluded. 
 
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 sacral nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacral nerve stimulator (64561, 95971, 95972, 51715).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet light therapy cabinet system. 
 
You asked the Plan to pre-approve an ultraviolet light therapy cabinet system. 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 ultraviolet cabinets are covered for selected patients 
with generalized intractable psoriasis. 
 
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 ultraviolet light therapy cabinet 
system. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
record indicates that you have mycosis fungoides. The record provided does not establish the diagnosis of 
generalized intractable psoriasis. 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 an ultraviolet light therapy cabinet system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultraviolet light therapy cabinet system.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral mandibular advancement device (E0486). 
 
You asked the Plan to pre-approve an oral mandibular advancement device. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a custom fabricated mandibular advancement oral 
appliance (E0486) used to treat obstructive sleep apnea (OSA) is covered if certain 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 an oral mandibular advancement 
device. Our reviewer says that the services are medically necessary. Our physician reviewer found you have a 
diagnosis of obstructive sleep apnea and sleep test results from October 18, 2023 qualify for criteria outlined 
for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oral mandibular advancement device have been met. Therefore, we decided 
that the Plan has to pre-approve an oral mandibular advancement device (E0486).  
 
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: 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 the enrollee would benefit from an IRF admission. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower 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.