Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal arthrodesis using the Minuteman device. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that  the enrollee is in severe pain, and 
the surgery is medically necessary. The Plan denied your request. The Plan says the arthrodesis using the 
Minuteman device is not medically necessary. The Plan says the Minutemen device is considered experimental 
and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this 74-year-old female was being treated for spinal instabilities of the 
lumbar region. She presented with lower back pain rated at 6/10. Her pain is worse with standing and walking. The exam reveals a restricted range of motion in extension with pain. Lumbar facet pain is negative bilaterally. 
 
However, current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) 
instability have not been documented and/or met in this case. In addition, there are multiple alternate pain 
generators plausibly significantly contributing to the clinical condition that have not been fully documented as 
having been excluded and/or ruled out. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested Minuteman 
device 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 the Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal arthrodesis using the Minuteman device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options, upgraded electronics, calf panel, and foot brackets. 
 
You asked the Plan to pre-approve the upgraded electronics, calf panel, and foot brackets. You say that these 
features are medically necessary and not for convenience. The Plan denied your request. The Plan says the 
notes do not show that the requested power options need to be operated with a joystick. The Plan says that a 
calf rest/pad is included in the requested power wheelchair code for the Group 3 power wheelchair. The Plan 
also says that the foot plates were requested with the wrong code. 
 
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 upgraded electronics, calf panel, 
and foot brackets. Our reviewer says that the requested upgraded electronics, calf panel, and foot brackets are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
documentation indicates that the enrollee has adequate strength to manage power drives and does not require a 
joystick. The reviewer found that the requested calf pads/rests are included in the approved power wheelchair. 
The reviewer also says that the provided documentation does not support a physical feature or deformity which 
would require the footplate width extension. Therefore, the reviewer found that the requested upgraded 
electronics, calf panel, and foot brackets are 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 the upgraded electronics, calf panel, and foot brackets have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options, upgraded electronics, calf panel, and foot brackets.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve the drug. You say that Prolia is medically necessary for the treatment of the 
enrollee's condition. The Plan denied your request. The Plan says that the step therapy requirements have not 
been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that Prolia 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drugs pamidronate and zoledronic acid. Also, there is no indication that the Plan's required drugs 
would likely be less effective or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee can receive the care needed in the current 
acute care setting. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that physical therapy will cause more pain. 
The Plan denied your request. The Plan says you do not meet the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
under certain medical 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 the requested services. Our physician 
reviewer found that you are being treated for wedge compression fracture of L1 vertebra. You presented with 
chronic back pain from a fall at the end of January. The exam reveals no tenderness with a full range of motion. 
Strength, sensation, and reflexes are intact. However, detailed documentation is not evident regarding an acute 
or subacute L2 compression fracture. Additionally, there is no documentation of a progression of the body 
height loss or a severe impact on daily activities. Moreover, there is magnetic resonance imaging (MRI) 
corroboration of other plausible causes of pain. Therefore, the requested service is not indicated for your 
condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 18, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that when either 5-50 or >50 gene panels are ordered, 
is considered incorrect coding. Correct coding requires that when a panel code is ordered, it should be billed, 
rather than the individual gene codes. 
 
We looked at the file and Medicare rules. The panel in this case was billed with several codes, rather than a 
single panel code required by LCA A56199. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 4, 2023, billed with 
codes 87500, 87641, 87653, 87640, 87481 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 4, 2023, billed with codes 87500, 87641, 87653, 87640, 87481 and 87798.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says that the records provided do not support the medical 
necessity for additional home health visits. 
 
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. medical records were requested, however, the only file sent in was missing the 
medical records. Therefore, we decided that the Plan has to pre-approve home health services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on September 9, 2022, billed 
with codes 87481, 87491, 87529, 87563, 87591, 87625, 87640, 87653, 87661 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on September 9, 2022, billed with codes 87481, 87491, 87529, 87563, 87591, 87625, 87640, 
87653, 87661 and 87798.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 units of code 96366 billed on date of service December 5, 
2022. 
 You asked the Plan to pay for 2 units of code 96366. You say that 2 units of 96366 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 2 units of 96366 
is 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. The rules also say that when billing multiple 
units of a HCPCS/CPT code, providers must enter the actual number of units provided on the claim form.  
 
In this case, the CPT Code Manual definition of code 96366 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); each additional hour (list separately in addition to code for primary 
procedure). 
 
We find that 2 units of CPT code 96366 are not supported in the medical record. Specifically, the code 
definition is time-based, and the records submitted for review do not document the total time spent providing 
the services described by 2 units of this code. Based on this information, we decided that Medicare rules for 
coverage of 2 units of code 96366 have not been met. Therefore, we decided that the Plan does not have to pay 
for 2 units of code 96366 billed on date of service December 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve the PVA procedure. You say that this procedure is necessary to treat the 
pain from this compression fracture. The Plan denied your request. The Plan says this is not medically 
necessary in this case.  
 
The Plan follows Medicare rules. Medicare rules say that PVA may be covered when the criteria listed in the 
Medicare rules section of this decision 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 the PVA procedure. Our reviewer says 
that the LCD criteria for coverage of the requested PVA procedure are not met. Our physician reviewer found 
the documentation does not support that the enrollee has an acute or subacute osteoporotic vertebral 
compression fracture confirmed by recent advanced imaging. In addition, it is not clear that the enrollee's 
current back pain is primarily due to the identified vertebral compression fracture. 
 
 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 PVA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous vertebral augmentation (PVA).
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 inpatient rehabilitation is both physically and 
medically necessary for the enrollee to return home at maximum level of functioning with decreased risk for 
readmission. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in 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 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 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.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81226 billed for date of service May 3, 2023. 
 
You asked the Plan to pay for procedure code 81226. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says that this code has a status indicator of "X" 
which means it cannot be paid under the physician fee schedule. 
 
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, procedure code 81226 represents a laboratory service. Laboratory 
services are paid under the clinical laboratory fee schedule, not the physician fee schedule. A status indicator of 
X does not preclude payment of this service under the appropriate fee schedule. The Plan has not provided 
sufficient reason for denial of this service. Therefore, we decided that the Plan has to pay for procedure code 
81226 billed for date of service May 3, 2023.  
 
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 pay for procedure code 70450 billed for date of service May 24, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that 70450 should be paid as billed because the 
enrollee had multiple procedures on the same date of service. The Plan denied your request. The Plan says 
payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 provided on April 19, 2023. 
 
You asked the Plan to pay for procedure code 96372. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is 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. 
 
We find that CPT code 96372 is not supported in the medical record. Specifically, code 96372 has a status 
indicator of Q1, per Addendum B - OPPS Payment by HCPCS Code for 2023. This service was billed the same 
day as code 99284 that has a status indicator of "V". Based on this information, we decided that Medicare rules 
for coverage of procedure code 96372 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 96372 provided on April 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block of the left knee (64454). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee   
 
replacement surgery. The review has determined that the requested genicular nerve block of the left knee 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block of the left knee (64454).