Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Continuous Positive Airway Pressure (CPAP) device (E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the device is medically necessary. The Plan 
denied your request. The Plan says that the enrollee had a 3-month trial rental period inappropriately authorized 
on January 6, 2023. The enrollee's sleep study was done in January 2017, and it does not meet Medicare criteria 
for the use of a CPAP device. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 CPAP device. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had polysomnography on January 4, 2017. The AHI was normal at 1.1, but the RDI 
was increased at 20. According to Medicare criteria, either an AHI or RDI greater than 15 meets criteria for 
CPAP therapy. On a visit March 20, 2023, the records show the enrollee is 99% compliant. The enrollee has 
shown excellent compliance with use of the device. The denial is reversed. 
 
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 CPAP device have been met. Therefore, we decided that the Plan has to pre-
approve a Continuous Positive Airway Pressure (CPAP) device (E0601).  
 
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 an IRF admission is medically necessary, reasonable, 
and appropriate. The Plan denied your request. The Plan says the enrollee 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 enrollee does 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  
 
Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  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 health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a leadless pacemaker placement (33274) provided on 
November 30, 2022 to December 1, 2022. 
 
You asked the Plan to pay for the leadless pacemaker placement. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for dates of service on or after January 
18, 2017, contractors shall cover leadless pacemakers through Coverage with Evidence Development (CED) 
when procedures are performed in CMS-approved CED studies.  
 
We looked at the file and Medicare rules. The records do not include documentation of the service being part of 
an approved clinical trial. Based on this information, we decided that Medicare rules for coverage of the 
leadless pacemaker placement have not been met. Therefore, we decided that the Plan does not have to pay for 
a leadless pacemaker placement (33274) provided on November 30, 2022 to December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an H200 Wireless Hand Rehabilitation System (E0770).  
 
You asked the Plan to pre-approve an H200 Wireless Hand Rehabilitation System. You say that you would like 
the denial to be reconsidered and the requested device to be approved to help the enrollee achieve their 
functional needs with their left hand. The Plan denied your request. The Plan says the requested item does not 
meet the Medicare requirements for coverage and does not meet the definition of being reasonable and 
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 an H200 Wireless Hand Rehabilitation 
System. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the 
records did not clearly describe that you have a spinal cord injury as required for NMES treatment. The nerves 
in this case would not effectively respond to this type of treatment due to the permanent damage related to the 
stroke. Our reviewer also found that you do not have an indicated condition 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 H200 Wireless Hand Rehabilitation System have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an H200 Wireless Hand Rehabilitation System (E0770).
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 for intensive rehabilitation 
since it would help regain functional levels of the enrollee's cognitive and physical conditions. The Plan denied 
your request. The Plan says the IRF services requested 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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block.  
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says a genicular nerve block is 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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the role of genicular nerve blocks in the treatment of knee osteoarthritis is 
the subject of ongoing clinical trials and is considered experimental. Therefore, the request is deemed 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not require an intensive team for their 
care. The services the enrollee needs can be provided safely in other settings like at a skilled nursing facility. 
 
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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for lower extremity vascular surgery complicated by compartment syndrome. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does 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 this 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99442 for date of service January 9, 2023. 
 
You asked the Plan to pay for procedure code 99442. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the documentation shows 
that the provider previously rendered services identified with code 99213 on January 9, 2023. This means services identified with code 99442 was provided within the excluded seven day period following procedure 
99213 and is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99442 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99442 for date of service January 9, 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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee continues to require care at an acute hospital. The enrollee can receive 
further care at the current acute care hospital or a lower level of care when deemed appropriate.  
 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service January 22, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 99284 billed for date of service January 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a STIMQ peripheral nerve stimulator (64555). 
 
You asked the Plan to pre-approve a STIMQ peripheral nerve stimulator . You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 STIMQ peripheral nerve stimulator. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental. 
 
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 STIMQ peripheral nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a STIMQ peripheral nerve stimulator (64555).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81455) provided on May 18, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
covered by Medicare. The Plan denied your request. The Plan says that this claim is denied. 
 
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. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated or fully 
explained their denial in this case. Therefore, we decided that the Plan has to pay for laboratory services 
(81455) provided on May 18, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan and echography. 
 
You asked the Plan to pre-approve CT scan and echography. You say that the enrollee has abnormal weight 
loss and you want to find the cause. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary. 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 CT scan and echography. Our reviewer 
says that these tests do not meet criteria for coverage. Our physician reviewer found the records provided were 
limited and do not support a reasonable indication for advanced imaging. There were no findings on the 
abdominal CT that warranted chest CT or ultrasound, and there was no record of having completed a workup of 
labs and other testing to warrant follow-up with CT or ultrasound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan and echography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan and echography.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 26, 2022, to 
August 24, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 26, 2022. The NOA was not received by the Plan until October 6, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from July 26, 2022, to August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement (11045) provided on April 13, 2022. 
  You asked the Plan to pay for debridement (11045). The Plan denied your request. The Plan says procedure 
code 11045 was billed without an appropriate primary procedure code. 
 
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 11045 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for debridement (11045) provided on April 13, 2022.