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

 
We decided that the Plan does not have to pay for two units of procedure code 64488 rendered on July 22, 
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 the records do not indicate a distinct second procedure of CPT 64488 performed on a separate 
patient encounter on the billed date of service. 
 
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 64488 is "Transversus abdominis plane (TAP) block 
(abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when 
performed)." 
 
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 not supported by the medical records. Our reviewer found that CPT 64488 is a bilateral 
procedure and includes multiple injections. Also, the medical records do not include sufficient documentation 
to validate a distinct procedure of 64488 being performed on any other separate encounter on July 22, 2023; 
therefore, the additional units of 64488 cannot be verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 64488 rendered on July 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 assistance with daily living and 
mobility. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that due to the enrollee's cognitive decline this scan 
is needed to guide management and confirm a diagnosis for infusion therapy. The Plan denied your request. 
The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
 
  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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the records provided for review 
indicated that the enrollee has been affirmatively diagnosed with AD. There was no mention of the patient 
meeting diagnostic criteria for both AD and FTD as required by the NCD for performance of said testing. If 
testing was being ordered for consideration of Lequembi, then that would be represented by a different current 
procedural terminology code (for beta amyloid PET) rather than the FDG PET ordered in this case. In as much 
the request as currently made would not meet the NCD requirements for coverage. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the tibial nerve simulator. 
 
You asked the Plan to pre-approve the tibial nerve simulator. You say that the enrollee has been on dual 
medication therapy and continues to have incontinence. You say that the enrollee's goal is to improve on their 
urgency and to get off their current medication. The Plan denied your request. The Plan says the tibial nerve 
simulator is considered experimental.  
 
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 tibial nerve simulator. Our reviewer 
says that the tibial nerve stimulator is not medically necessary. Our physician reviewer found that the records 
do not support that the tibial nerve simulator (eCoin device) at issue in this case meets all Medicare criteria for 
medically reasonable and necessary 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 tibial nerve simulator.  have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the tibial nerve simulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that the recommended provider does not have 
experience with your condition. The Plan denied your request. The Plan says there are providers available 
within the network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
urology services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
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 that the enrollee's needs are currently being met in the acute care settings. The 
documentation does not support that the enrollee will need greater than a 25 day stay. Furthermore, a transfer to 
an LTACH would not provide new services. 
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compression device (E0652, E0656, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show an initial treatment with the requested device (E0652) with 
limb and trunk measurements to evaluate clinical response. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded with 
E0652 is covered for lymphedema extending into the chest, trunk, or abdomen. 
 
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 device. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has lymphedema extending into the trunk. The enrollee's lymphedema which has no 
responded to conservative treatment, or a four week trial of E0651. 
 
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 device have been met. Therefore, we decided that the Plan has to pre-
approve a pneumatic compression device (E0652, E0656, E0667).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve the nerve blocks. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the nerve blocks. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has evidence of multiple other pain generators. Therefore, the criteria of the 
LCD are not 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 the nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve medial branch blocks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test provided on June 20, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are 
not met. 
 
The Plan follows Medicare rules. Medicare rules say that Melanoma Risk Stratification Molecular Testing is 
covered for the indications established in the applicable LCD. 
 
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 pay for the testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary. Our physician reviewer found that the enrollee's 
melanoma is a Stage 1a, without ulceration and no evidence for microstaging. The enrollee does not meet the 
LCD coverage criteria. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the DecisionDx-Melanoma test provided on June 20, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the InnovaMatrix AC skin substitute. 
 
You asked the Plan to pre-approve the InnovaMatrix AC skin substitute. You say that the wound is extremely 
painful and you have been on a lot of medications for it. You say you can hardly walk and it has impacted your 
quality of life. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the InnovaMatrix AC skin substitute. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found you are suffering with a nonhealing venous ulceration to the left lower 
extremity. The medical documentation supports that the ulceration to the left lower extremity has not healed 
after at least six weeks of standardized wound care. In fact, the ulceration has enlarged. Our reviewer says 
advanced wound care is medically reasonable and necessary at this time in order to heal the ulceration quickly 
and reduce the chance of infection and or osteomyelitis. Therefore, the requested application of InnovaMatrix 
AC skin substitute to your left lower extremity ulceration is 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 InnovaMatrix AC skin substitute have been met. Therefore, we decided that 
the Plan has to pre-approve the InnovaMatrix AC skin substitute.  
 
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: Partially Favorable

 
We decided that the Plan has to pre-approve one unit of complex radiation therapy field setting described by 
code 77290. We decided that the Plan does not have to pre-approve one unit of simple radiation therapy field 
setting described by code 77280. 
 
You asked the Plan to pre-approve electronic brachytherapy treatment. You say that you disagree with the 
denial. The Plan says that the services are not medically necessary. 
 We decided that the Plan has to pre-approve one unit of complex radiation therapy field setting 
described by code 77290. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
one unit of complex radiation therapy field setting is medically necessary and one unit of simple radiation 
therapy field setting is not medically necessary. Our physician reviewer found that the records show that you 
have a diagnosis of skin cancer. The use of simple radiation field setting described by code 77290 is not 
supported by the submitted records, as ultrasound to determine the depth and size or target is more 
appropriately billed as a simple versus complex simulation. One unit of complex radiation field setting 
described by code 77290 is medically necessary for the first day of treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve one unit of complex radiation therapy field setting described by code 77290. 
 
We also decided that the Plan does not have to pre-approve one unit of simple radiation therapy field 
setting described by code 77280. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
one unit of complex radiation therapy field setting is medically necessary and one unit of simple radiation 
therapy field setting is not medically necessary. Therefore, we decided that the Plan does not have to pre-
approve one unit of simple radiation therapy field setting described by code 77280. 
 
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: 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 you are requesting an expedited appeal 
and have provided a clinical summary and clinical documentation to support this request. The Plan denied your 
request. The Plan says the request for LTACH services to be covered does not meet the requirements for 
approval. 
 
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 does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. You asked the Plan to pre-approve a Freestyle Libre 2. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 2. Our reviewer says 
that the CGM is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not 
satisfied. 
 
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 Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 2.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan 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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that Vertiflex is experimental. 
 
   
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).