Persius/hicric huggingface dataset:
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 has a decline in their functional mobility 
and would benefit from the services received in an IRF. The Plan denied your request. The Plan says the 
enrollee does 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 the enrollee does 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for chiropractic care on May 08, 2023, to May 
11, 2023.  
 
You asked the Plan to waive the deductible for chiropractic care. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $950 deductible which applies to chiropractic services.  
 
The item or service you asked the Plan to waive the deductible for falls within the chiropractic services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $950 
deductible which applies to chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time chiropractic care was received on May 8, 2023, to May 11, 2023. Therefore, we decided that the 
Plan does not have to waive the deductible for chiropractic care on May 08, 2023, to May 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 1 home health skilled nursing visit and 12 home health 
physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the records provided support the need 
for the services being requested. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the enrollee requires additional skilled nursing services or skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to 
improve the enrollees condition, perform a maintenance program to maintain the enrollees condition and/or 
prevent deterioration.  The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations.  The requested home health services are not medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 1 home health skilled nursing visit and 12 home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted musculoskeletal surgical 
navigational orthopedic procedure, with image-guidance (0055T) and an inpatient admission (0150). 
 
 You asked the Plan to pre-approve a MAKOplasty with an inpatient admission. You say that you disagree with 
the denial and request reconsideration. The Plan denied your request. The Plan says the current evidence-based 
medical literature does not support the routine use of computer-assisted navigated total hip arthroplasty over 
conventional total hip arthroplasty. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. 
 
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 MAKOplasty with an inpatient 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested total hip arthroplasty is documented to have 
been supported. However, there is limited published, large-scale, long-term peer-reviewed literature that shows 
this specific request to be an effective and/or safe treatment for the noted pathology. The clinical benefits 
(including ultimate outcomes of functional improvement and pain reduction) with computer navigation have 
not been evidenced in large volume long-term studies. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested MAKOplasty for the approved total hip arthroplasty (THA) 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 MAKOplasty with an inpatient admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computer-assisted musculoskeletal surgical navigational 
orthopedic procedure, with image-guidance (0055T) and an inpatient admission (0150).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service May 16, 
2023.  
 
You asked the Plan to pay for procedure code 88360. You say that you disagree with the Plan's denial. 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 88360 is 6. The MAI value for this code is 3. You billed 8 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 88360 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88360 billed for date of service May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation, including cavity 
creation using a mechanical device (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that you disagree with the denial. The Plan denied 
your request. The Plan says Medical necessity is not demonstrated because there is insufficient documentation 
on advanced imaging to exclude contraindications to the procedure. 
 
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 kyphoplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for wedge compression of the first lumbar vertebra. She 
presented with chronic lumbar pain but has had increased, excruciating pain that is different since March 2023. 
She presented to the emergency department and was found to have compression fracture of L1. The exam 
reveals intact strength, sensation, and reflexes. There is positive facet loading bilaterally. However, detailed 
documentation is not evident regarding the L1 fracture being acute or subacute, as it was noted to have been 
present in March 2023. Additionally, there is no documentation of a greater than 25% vertebral body height 
loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is an MRI corroboration of 
retropulsion and other plausible causes of pain. Therefore, the enrollee does not meet criteria for approval of 
kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous vertebral augmentation, including cavity creation using a mechanical 
device (22514).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 home health skilled therapy visits.  

You asked the Plan to pre-approve home health skilled therapy visits. You say that the enrollee still has wound 
care needs and is unable to care for themself. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that LLE wound has stabilized. Without any further changes in plan of care, medication 
regimen or clinical status changes the records do not show that the additional home health skilled nursing visits 
are required to effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 home health skilled therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22515, 22514). 
 
You asked the Plan to pre-approve kyphoplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of bracing for fracture 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22515, 22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service April 27, 
2023.  
 
You asked the Plan to pay for procedure code 69990. You say that there were three levels involved with this 
surgery. The Plan denied your request. The Plan says payment for code 69990 is bundled into payment for code 
63047. 
 
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 69990 
is a column II code to column I code 63047 with a modifier indicator of 0. The column II 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 69990 billed for date of service April 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revascularization procedure right tibial artery (37228-
37235). 
 
You asked the Plan to pre-approve a revascularization procedure right tibial artery. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 revascularization procedure right tibial artery. 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 support the medical necessity 
of the treatments in question. There is no documentation suggesting limb threat. It is specifically documented 
that she does not have pain at rest and does not have ulcerations. The documentation is not at all clear that the 
enrollees walking limitation is due to claudication, specifically the enrollee was not exercised due to unsteady 
gait and needing assistance to transfer. The ankle-brachial index (ABI) demonstrates pressures in the right 
tibial arteries of greater than 250 mmHg consistent with being detectable, but the arteries were 
noncompressible. Therefore, the report of being nondetectable is inaccurate. It is not clear that the enrollee 
would experience any meaningful improvement in walking distance from intervention and as noted above, 
there is no sign of limb threat. 
 
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 revascularization procedure right tibial artery have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a revascularization procedure right tibial artery (37228-
37235).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87801 for date of service 
December 6, 2022. 
 
You asked the Plan to pay for procedure codes 87150 and 87801. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87150 and 87801 are not supported in the medical record. Specifically, the laboratory 
report includes documentation regarding the methodology (PCR) for the assay panel(s) performed but does not describe culture and typing by nucleic acid probe. There is one report submitted for review and no results are 
provided for CPT 87150; therefore, code 87150 is not supported. The documentation does not show any 
multiple organism or groups listed in the result; therefore, code 87801 is not supported. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87150 and 87801 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150 and 
87801 for date of service December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature (L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor 
control feature, swing and stance phase (L5856), an all-lower extremity prostheses, flex-walk system (L5981) 
and an all lower-extremity prostheses, multi-axial rotation unit (L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee needs the replacements so he can 
continue to be safe for ambulation. The Plan denied your request. The Plan says the records do not show why 
the requested advanced feet and knees are needed. 
 
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 prosthetics. 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 K3 level 
microprocessor knees and feet meet Medicare criteria for coverage. Provided medical records do not fully 
support the enrollee's ability to perform at a K3 level and the necessity of microprocessor knees and feet over 
mechanical ones is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an 
addition to endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), an addition to 
lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase (L5856), an all-lower extremity prostheses, flex-walk system (L5981) and an all lower-extremity 
prostheses, multi-axial rotation unit (L5856).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MAKOplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
unilateral primary osteoarthritis of the left knee. The left knee total arthroplasty has been approved. There are 
no large volume, long-term/high-quality clinical studies confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in 
total knee arthroplasty. No compelling rationale or extenuating circumstances are noted to support the medical 
necessity of this request as an exception to guidelines. Therefore, the requested MAKOplasty for the approved 
total knee arthroplasty 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MAKOplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft, morselized, or placement of osteopromotive 
material, for spine surgery only (20930) and bone marrow aspiration for bone grafting (20939) 
 
You asked the Plan to pre-approve bone marrow aspirate and the Depuy Synthesis Vivigen allograft. You say 
that you disagree with the denial. The Plan denied your request. The Plan says the clinical value and 
effectiveness of bone marrow aspirate and Depuy Synthesis Vivigen allograft in the setting of spinal and 
cervical fusion surgery, have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate and the Depuy 
Synthesis Vivigen allograft. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found osteopromotive allograft and bone marrow 
aspirate are experimental and investigational in spine surgery. Iliac crest bone graft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate and the Depuy Synthesis Vivigen allograft have not been 
met. Therefore, we decided that the Plan does not have to pre-approve allograft, morselized, or placement of 
osteopromotive material, for spine surgery only (20930) and bone marrow aspiration for bone grafting (20939)