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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct.  
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
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 patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure (30469, 30117, 30801). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that Original Medicare covers nasal airway 
remodeling with the requested procedure codes. The Plan denied your request. The Plan says there is 
insufficient literature to support the safety and efficacy of radiofrequency treatment of nasal valves for the 
treatment of nasal airway obstruction. 
 
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 VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has nasal obstruction. There is insufficient 
literature to support the safety and efficacy of the requested service for the enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. Therefore, the reviewer found that the requested VivAer procedure 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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure (30469, 30117, 30801).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a new bladder stimulator. 
 
You asked the Plan to pre-approve placement of a new bladder stimulator. You say that placement of a new 
bladder stimulator is medically necessary. The Plan denied your request. The Plan says the guidelines say this 
is not a covered service for bladder problems like you have.  
 The Plan follows Medicare rules. Medicare rules say that the use of spinal cord electrical stimulators, rectal 
electrical stimulators, and bladder wall stimulators is not considered 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 placement of a new bladder stimulator. 
Our reviewer says that placement of a new bladder stimulator is not considered medically reasonable and 
necessary. Our physician reviewer found placement of a new bladder interstim stimulator is not medically 
necessary because the records do not show that you urge incontinence, urgency-frequency syndrome, non-
obstructive urinary retention, or overactive bladder with a non-functional interstim in place. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a new bladder stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve placement of a new bladder stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311) and power seat elevation system (E2300) for the enrollee.
You asked the Plan to pre-approve an expandable controller, harness, electronic connection and power seat elevation system. You say that these items should be covered. The Plan denied your request. The Plan says that the enrollee's upper limb strength and function are adequate to use the provided switches.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller, harness, and electronic connection. Our Medical Director states that the enrollee is a patient with a diagnosis of multiple sclerosis who requires a power wheelchair for mobility. Provided records document that the enrollee has "full strength BUE [bilateral upper extremities]" with 3+/5 to 4-/5 grip and that she is independent with feeding, bathing, grooming, and dressing, thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an expandable controller, harness, and electronic connection. We looked at this physician's review, the file, and Medicare rules. A power seat elevation feature (E2300) are non-covered because they are not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness, electronic connection and power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311) and power seat elevation system (E2300) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 16, 2023.  
 
You asked the Plan to pay for the lab services. You say that this testing is medically necessary and is covered 
by Medicare. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on May 16, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 20, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 11, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 2 standard power wheelchair (K0823), U-1 sealed lead 
acid battery (E2365), and detachable armrest (E0973). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and accessories. You say that you only 
get around by using a rollator walker, and you can only stand for a limited amount of time. You also say that 
you have limited movement in your left hand, and you would not be able to tolerate a manual wheelchair. The 
Plan denied your request. The Plan says that you do not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 standard power wheelchair 
and accessories. Our reviewer says that the group 2 power wheelchair is medically necessary. Our physician 
reviewer found you are functionally non-ambulatory, and your current group 2 power wheelchair is in disrepair 
and can no longer be repaired. You have impaired shoulder range of motion and upper extremity strength and 
cannot propel a manual wheelchair functional distances. Our reviewer found that you cannot operate a power 
scooter due to impaired sitting balance. You require a group 2 power wheelchair for mobility and performing 
your daily activities. Our physician reviewer also found that you are noted to be able to safely operate the 
requested group 2 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  
a group 2 standard power wheelchair and accessories have been met. Therefore, we decided that the Plan has to 
pre-approve a group 2 standard power wheelchair (K0823), U-1 sealed lead acid battery (E2365), and 
detachable armrest (E0973).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 rendered on January 5, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that this code is not appropriate for the services billed. 
 
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 J3490 is "Unclassified drugs." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the medical documentation does 
support the use of procedure J3490, and the claim has the required coding guidelines for the use of J3490 when 
being used for unclassified drugs. Bupivacaine was used to refill the patient pain pump. The coding 
requirements have been met and does support the use of J3490. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code J3490 rendered on January 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee and flex foot with hydraulic 
ankle (L5828, L5845, L5856, L5848, L5981, L5968). 
 
You asked the Plan to pre-approve the microprocessor knee and flex foot with hydraulic ankle. You say that 
these items are medically necessary. The Plan denied your request. The Plan says the requested prosthetic 
features are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 microprocessor knee and flex foot 
with hydraulic ankle. Our reviewer says that the requested features are not medically necessary. Our physician 
reviewer found the documentation does not support that the patient's functional level requires a microprocessor 
knee over a mechanical knee. The requested advanced knee and foot exceed his needs. 
 
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 microprocessor knee and flex foot with hydraulic ankle have not been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor knee and flex foot with 
hydraulic ankle (L5828, L5845, L5856, L5848, L5981, L5968).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power operated vehicle (K0806). 
 
You asked the Plan to pre-approve a group 2 standard power operated vehicle. You say that you need this 
power operated vehicle, as you cannot move, and your kids are unable to take care of you at home. The Plan 
denied your request. The Plan says based on Medicare guidelines, the group 2 standard power operated vehicle 
requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 standard power operated 
vehicle. Our reviewer says that the group 2 power wheelchair is not medically necessary. Our physician 
reviewer found there is a lack of clinical documentation indicating your level of mobility, function, and 
physical examination findings, specifically with regards to motor strength in the upper and lower extremities. 
There is no indication that you cannot use a cane or walker for assistance with mobility or propel a manual 
wheelchair. Our reviewer also found that there is a lack of information as to whether you can safely operate the 
requested power mobility device and if your home is accessible. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 standard power operated vehicle (K0806).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device (22869).  
 
You asked the Plan to pre-approve the Minuteman device. You say that you feel this service should be 
approved. The Plan denied your request. The Plan says there is a lack of evidence (only a retrospective series) 
on the efficacy of interspinous fixation devices as a stand-alone procedure for those who have spinal stenosis 
and/or spondylolisthesis. 
 
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 device. Our reviewer 
says that the requested Minuteman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Minuteman device is experimental for use in spine surgery as more research 
is needed. Therefore, the reviewer found that 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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. The Plan denied your request. The Plan says as 
the enrollee is not on insulin and does not have documentation of problematic hypoglycemia, a CGM is not 
covered under current Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 3, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service January 3, 2023.