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

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with multiple 
power options (K0843). 
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair. The Plan denied your request. The 
Plan says there is no precedence for this request to be approved.  
 
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 heavy duty power wheelchair. 
Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the 
documentation available for review does not support that you require a power mobility device to accomplish 
mobility related self-care tasks in the home. Our reviewer also found that there is no indication that you are 
unable to use an alternative assistive device. 
 
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 heavy duty power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with multiple power 
options (K0843).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services billed for codes 14040, 26418, and 
26860 for date of service January 17, 2023. 
 
You asked the Plan to pay for the surgical assistant services. You say that the complexity of the procedures 
required a surgical assistant. The Plan denied your request. The Plan says surgical assistant services are not 
covered for the codes billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 14040, 26418, and 26860. The Medicare Fee Schedule Database contains 
a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant 
surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does 
not have to pay for surgical assistant services billed for codes 14040, 26418, and 26860 for date of service 
January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amniowrap2, per square centimeter (Q4221). 
 
You asked the Plan to pre-approve wound care. You say that you are requesting reconsideration due to a foot 
ulcer. The Plan denied your request. The Plan says the records do not show that you have failed standard 
wound therapy. The enrollees blood sugar remains controlled, and proper blood sugar control is necessary to 
optimize wound healing. 
 
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 wound care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested service does not meet criteria outlined and is 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 wound care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Amniowrap2, per square centimeter (Q4221).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollees medical, rehab, and nursing needs (combined complexity) requires an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. At the current 
functional level with aphasia and cognitive deficits, the enrollee needs intensive therapies consisting of at least 
3 hours of therapy per day (ST, PT and OT) at least 5 days per week with multidisciplinary approach in an IRF. 
The enrollees rehab needs cannot be safely provided in an alternate and low intensity setting such as in a 
skilled nursing facility (SNF). 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this should be approved. The Plan 
denied your request. The Plan says the record shows non-vertebrogenic pathology at the requested levels that 
could explain the source of the enrollee's pain. The Plan also says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not indicate a clear cause of the enrollee's pain. 
Therefore, the reviewer found that the requested Intracept 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty services provided on January 18, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the arthroplasty services. You say that you were told all services involving this 
knee replacement were covered. The Plan denied your request. The Plan says the services were received from 
an out of network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the arthroplasty services provided on January 18, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 6, 2023. 
 
You asked the Plan to pay for the physician's services. You say that at the time of service the member was 
residing in assisted living and the doctor was not responsible to obtain authorization. You say the assisted 
living facility was responsible to obtain authorization, which should also cover the medical treatment provided 
by the doctor. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-
network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20553 billed for date of service May 11, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the documentation supports the code. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 20553 is injection(s); single or multiple trigger point(s), 3 
or more muscles. We find that CPT code 20553 is not supported in the medical record. The records show that 
the cervical paraspinal muscle and the trapezius muscle were injected. The records do not show that trigger 
point injections were provided to 3 or more muscles Based on this information, we decided that Medicare rules 
for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20553 billed for date of service May 11, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require more time in an IRF. The Plan denied 
your request. The Plan says you do not meet the criteria for 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record complies with the various documentation requirements for IRF admission. Your 
condition is in fact complex, and there is every reason to expect that you will participate in and benefit from 
services to include at minimum physical and occupational therapy, physician oversight, polypharmacy, and 
case manager coordination of any additional services that might be needed to make a sustainable return home 
as well as avoid preventable readmissions to the acute hospital. Therefore, the requested inpatient rehab facility 
admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM sensor. You say that it is very important that the 
enrollee receives this device due to her need to check her blood sugar often. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the requested CGM sensor. 
 
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 Dexcom G6 CGM sensor. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 Mis continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 14, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81408, 
81408, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that medical records were submitted. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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. The file shows that a comprehensive test panel was provided. We looked at the file and Medicare rules. This 
panel testing was not billed with a single code as required. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing provided on October 14, 2022, billed with codes 81162, 81201, 
81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81408, 81408, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery; intermediate (77523). 
 
You asked the Plan to pre-approve proton treatment delivery. You say that you are requesting reconsideration 
and have submitted medical records for review. The Plan denied your request. The Plan says a review of the 
literature indicates that proton beam therapy for primary treatment of prostate cancer should only be performed 
within the context of a prospective clinical trial. 
 
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 proton treatment delivery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the use of proton therapy is an accepted radiation technology, which has proven 
efficacy and tolerability. Certain conditions such as base of skull chordomas and chondrosarcomas, and 
pediatric central nervous system (CNS) malignancies are probably best treated with proton therapy, due to the 
sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal 
tissue. There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage 
over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage 
of this expensive therapy. Nothing in the case file suggests that standard dosimetric constraints cannot be met 
with a non-proton-based treatment, and it is not plausible that proton therapy would be needed to meet these 
constraints. Simply demonstrating that proton therapy will reduce the low dose to normal tissues does not 
necessarily demonstrate that it is clinically needed relative to intensity-modulated radiation therapy (IMRT) 
though, as the reductions should be clinically meaningful, and reduce toxicity risks in a clinically meaningful 
manner. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on 
clinical trials, and to not routinely offer it to enrollees. While National Comprehensive Cancer Network 
(NCCN) guideline consider proton therapy a reasonable alternative they do not describe it as being necessary 
in lieu of non-proton based treatment and are quite explicit in that there is no evidence of its superiority. The 
decision is unfavorable as the reviewer does not believe the LCD criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery; intermediate (77523).
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 services are medically necessary for the enrollee 
to receive physician oversight and therapy services for their medical needs. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number 
of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services coded as 99222 
performed on February 6, 2023. 
 
You asked the Plan to pay for 99222. You say that 99222 should be covered as billed because it is supported in 
the documentation. The Plan denied your request. The Plan says 99222 is denied because it is not supported in 
the documentation. 
 
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 99222 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 minutes must be met or exceeded.  
We find that CPT code 99222 is not supported in the medical record. Specifically, it is not documented in the 
record that the enrollee was actually treated by the provider at issue until February 6, 2023, had ended. Records 
show the enrollee was treated by the provider at issue on February 7, 2023. Therefore code 99222 billed for 
date of service February 6, 2023, is not supported. Based on this information, we decided that Medicare rules 
for coverage of 99222 have not been met. Therefore, we decided that the Plan does not have to pay for 
evaluation and management services coded as 99222 performed on February 6, 2023.