Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revision of spinal neurostimulator electrode array 
(63663) and the insertion or replacement of spinal neurostimulator generator or receiver (63685). 
 
You asked the Plan to pre-approve the spinal cord stimulator revision and replacement. You say that you are 
requesting reconsideration based on medical necessity. The Plan denied your request. The Plan says the request 
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 spinal cord stimulator revision and 
replacement. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you are suggesting changing the battery to a different 
brand. There is a one unit per lifetime limit unless there is a defect in the unit or the leads. The loss of 
effectiveness of stimulation is not an indication that is covered. The request is deemed not medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the spinal cord stimulator revision and replacement have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the revision of spinal neurostimulator 
electrode array (63663) and the insertion or replacement of spinal neurostimulator generator or receiver 
(63685).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper 
or lower extremity arteries (93922) provided on August 15, 2023. 
 
You asked the Plan to pay for the study. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that I73.9 has an Excludes1 note in relation to I70.223. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the study have not been met. Therefore, we decided that the Plan does not have to pay for the limited 
bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided on August 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided on September 08, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the inpatient care 
provided on September 08, 2023.
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 Prolia. You say that the enrollee has been on oral bisphosphonate for seven 
years with modest response. The Plan denied your request. The Plan says the enrollee has not failed the 
formulary alternatives.  
 
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 Prolia. Our physician reviewer found 
that the enrollee has a history of age-related osteoporosis without a current pathological fracture. The Plan 
requires a trial an oral bisphosphonate and an injectable bisphosphonate before they will approve the requested 
drug.  In this case, there is no documentation that the enrollee has a history of failure, contraindication, or 
intolerance to both formulary alternatives, an oral bisphosphonate (e.g., alendronate, risedronate) and an 
injectable bisphosphonate (e.g., pamidronate, zoledronic acid).  There is no documentation provided indicating 
that the Plans required drugs would likely be less effective and/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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0953, E1028, E2377, E2313, E2373, 
E2363, E1007, E2311, E2620, E2622, E1012, E0955 and E1028). 
 
  You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that the patient is at heightened risk of mortality without the equipment requested. You also say that 
you feel the decision was incorrect since the patient does meet medical necessity based on Medicare guidelines 
for the tilt and recline seating system. The Plan denied your request. The Plan says the patient does not have a 
qualifying diagnosis causing mobility limitation for K0861 Group 3 power wheelchair listed on the quote 
submitted. As the base code for the requested wheelchair is not reasonable and necessary, none of the requested 
accessories can be approved. The Plan also says the electronic connection, expandable controller harness, and 
expandable controller cannot be covered as it is not medically necessary to control the three requested power 
options through the joystick (drive interface). 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that this request is not medically necessary. Our 
physician reviewer found the patient does not have a neurologic disorder causing her functional deficits. The 
patient does not have an appropriate diagnosis for a Group 3 power wheelchair. Our reviewer also found that 
although the patients condition may meet criteria for a power wheelchair, the criteria for this specifically 
requested power wheelchair are not met. 
 
We looked at this physician's review, the file, and Medicare rules. The file does not show that the enrollee has a 
mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Based on 
this information, we decided that Medicare rules for coverage of a Group 3 standard power wheelchair and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E0953, E1028, E2377, E2313, E2373, E2363, E1007, E2311, E2620, E2622, E1012, E0955 
and E1028).
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 requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for metabolic encephalopathy and COVID 19 infection and was transferred to skilled nursing. 
Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.  
 
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 pay for the continuous intraoperative neurophysiology monitoring 
provided on February 15, 2022. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that the 
services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the continuous 
intraoperative neurophysiology monitoring provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable underpads provided on July 17, 2023. 
 
You asked the Plan to pay for the incontinence supplies. The Plan denied your request. The Plan says this is not 
a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for the disposable underpads provided on 
July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99255 billed for date of service April 5, 2023. 
 
You asked the Plan to pay for code 99255. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed these services with an invalid code. The Plan must follow 
Medicare rules. Medicare rules say that code 99255 is no longer recognized.  Another code should be used to 
bill for inpatient or observation consultation services. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of code 99255 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99255 billed for date of service April 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
07, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient surgery/Medicare-covered surgery services. 
 
You have been asked to pay a $275 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an outpatient surgery provided on August 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture provided from May 31, 2022, to September 
27, 2022. 
 
You asked the Plan to pay for the acupuncture. You say that the claims were filed with the correct diagnosis 
code. The Plan denied your request. The Plan says the primary diagnosis is not a diagnosis that supports an 
acupuncture service for chronic lower back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the acupuncture have been met. The 
provider did not submit medical records after multiple attempts from the Plan. Therefore, we decided that the 
Plan does not have to pay for the acupuncture provided from May 31, 2022, to September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A44501, A6216 and A6222 billed for date 
of service April 30, 2023. 
 
You asked the Plan to pay for procedure codes A44501, A6216 and A6222. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says billed code A4450 is a statutory 
exclusion. Codes A6216 and A6222 are bundled/excluded codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4450 has a Status Indicator of X on the Physician Fee Schedule. Procedure 
codes A6216 and A6222 have a Status Indicator of P. This means that procedure codes A44501, A6216 and 
A6222 do not meet criteria for separate payment. Based on this information, we decided that Medicare rules for 
coverage of procedure codes A44501, A6216 and A6222 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes A44501, A6216 and A6222 billed for date of service April 30, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 15, 2022, to 
March 16, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 15, 2022. The NOA was not received by the Plan until December 
13, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 15, 2022, to March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arterial puncture, spirometry and pulmonary stress testing 
provided on March 22, 2023. 
 
You asked the Plan to pay for arterial puncture, spirometry and pulmonary stress testing. You say that this 
service is supported in the records. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for arterial puncture, 
spirometry and pulmonary stress testing provided on March 22, 2023.
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 requires continued medical care and 
intensive therapy. The Plan denied your request. The Plan says criteria for IRF care are not met.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pneumonia and altered mental status. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy for lysis of adhesions. 
 
You asked the Plan to pre-approve a knee arthroscopy. You say that the enrollee has tightness in their knee, and 
they need the scar tissue removed. The Plan denied your request. The Plan says the enrollee has not had 
structured outpatient physical therapy. 
 
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 knee arthroscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. There is no detailed documentation of 
trial and failure of aggressive physical therapy that has failed. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee arthroscopy for lysis of adhesions.