Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay for therapeutic activities (97530). We decided that the Plan does not have 
to pay for speech language pathology services (92507, 92526).  
 
You asked the Plan to pay for therapeutic activities (97530) and speech therapy services (92507, 92526) 
provided from January 6, 2023, to January 18, 2023. You say that these services were medically necessary. The 
Plan says that codes 92507 and 92526 were not billed with an appropriate diagnosis. A National Correct 
Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 97535 and 97530, so 97530 
cannot be paid. 
 
We decided that the Plan has to pay for therapeutic activities (97530).  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 97535 and 97530. However, this edit was terminated and was not active at 
the time the services were provided. The Plan has not provided a valid denial reasoning for this service. 
Therefore, we decided that the Plan has to pay for therapeutic activities (97530).  
 
We also decided that the Plan does not have to pay for speech language pathology services (92507, 
92526). 
 
 
 
 
 
 
 The Plan follows Medicare rules. Medicare rules say that limited diagnosis codes support medical necessity of 
speech language pathology services, including codes 92507 and 92526. Diagnosis I63.50, cerebral infarction 
due to unspecified occlusion or stenosis of unspecified cerebral artery, is not listed. 
 
We looked at the file and Medicare rules. The billed diagnosis code, I63.50, does not support medical necessity 
for codes 92507 and 92526. Therefore, we decided that the Plan does not have to pay for speech language 
pathology services (92507, 92526). 
 
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 pay for inpatient hospital services provided on September 27, 2022, 
to October 6, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code N17.9, described as Acute 
kidney failure, unspecified. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found that the enrollee is a 79-year-old female with a past medical history 
including hypertension, dementia and multiple sclerosis who was admitted to the hospital with dysarthria and 
confusion. She was noted to appear dehydrated and initial creatinine was noted at 1.7 with Estimated 
Glomerular Filtration Rate of 29. She received intravenous hydration in the emergency department and was 
noted to have urinary incontinence. Repeat laboratory testing showed a creatinine of 0.98. At the time of 
admission, the documentation did not support that the member had an increase within 48 hours of their 
creatinine that was at least 1.5X higher than their baseline. There is no documentation to indicate that the 
enrollee had a significant decrease in urinary output after initial treatment in the emergency department.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 27, 2022, to October 6, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent limb compression device. 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the records do not show measurements of the 
enrollee's legs before and after using the device for the first time showing the change in measurements before 
and after treatment. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. Determination of medical necessity must include certain documentation, including clinical 
response to an initial treatment with the device. 
 
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 intermittent limb compression device. 
Our reviewer says that the enrollee does not meet criteria for the requested pneumatic compression device. Our 
physician reviewer found the enrollee has lymphedema in the lower extremities. The enrollee has tried 
compression and manual lymph drainage without sufficient improvement. A pneumatic compression device 
was trialed; however, the records do not show the specific measurements of the enrollee's legs before and after 
using the device for the first time showing the change in measurements to confirm a measurable improvement 
to justify long-term use. Therefore, the pneumatic compression device is not considered medically necessary at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve intermittent limb compression device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vagus Nerve Stimulation (VNS).  
 You asked the Plan to pre-approve the Vagus Nerve Stimulation (VNS). You say that Vagus Nerve Stimulation 
(VNS) is medically necessary. The Plan denied your request. The Plan says that Vagus Nerve Stimulation 
(VNS) is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Vagus Nerve Stimulation is covered when the criteria 
listed in the Medicare rules section of this decision are met.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vagus Nerve Stimulation (VNS). Our 
reviewer says that Vagus Nerve Stimulation (VNS) is not considered medically necessary. Our physician 
reviewer found that there remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of VNS in post-stroke patient management. As a result, at this time the 
VNS system would not be considered medically reasonable and necessary in this enrollees clinical 
management. 
 
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 Vagus Nerve Stimulation (VNS) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vagus Nerve Stimulation (VNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute, Artacent ac, per sq cm (Q4190). 
 
You asked the Plan to pre-approve skin substitute. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the records do not show that the enrollee meets 
medical necessity criteria. The records document that skin substitutes have been used on the enrollee's left foot 
wounds for more than 6 months. The records do not demonstrate adequate conservative wound care either, with 
documentation of too tight compression and problems with drainage, infection, and blood flow in her leg. 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 skin substitute. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee had ulcers on her left leg and foot treated with "DHAM" 
amniotic allografts since at least January 2023. These lesions are characterized in the records as left foot 
"surgical wound," left heel "other," and left lower leg, "arterial related." A note from the enrollee "in home 
wound reassessment" provider from March 21, 2023, states that at that time she had already been receiving 
"advanced wound therapy utilizing DHMA," these amniotic grafts. That day, her provider documented "wound 
draining excessive fluid" and notation about concern about the blood flow in that leg. Earlier notes dating back 
to January 4, 2023, from this same in-home provider state that her left foot wound was a transmetatarsal 
amputation site. These earlier notes document "grafts placed." On April 10, 2023, her provider said that she 
was refusing home health visits and was stopping the compression wraps due to worsening of her leg problems. 
April 18, 2023, the records say that the enrollees wraps had been too tight. Per the reviewed 
documentation, the records document that skin substitutes have been used on the left foot wounds for more 
than 6 months. The records do not demonstrate adequate conservative wound care either, with documentation 
of too tight compression and problems with drainage, infection, and blood flow in the leg. The review has 
determined that the items/services at issue in this case are 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 skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin substitute, Artacent ac, per sq cm (Q4190).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service January 12, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the physician deemed the testing medically 
necessary. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the Plan paid 5 units of code 88374 based on the Medicare allowed amount. We find no exception 
which would require the Plan to pay for additional units. Therefore, we decided that the Plan does not have to 
pay for procedure code 88374 billed for date of service January 12, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 there are no evidence based or clinical practice standards for acute rehabilitation of 
osteoarthritis of the knee. 
 
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: 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. You say that the enrollee's medical condition and care 
requirements cannot be adequately addressed in a lower level of care. The Plan denied your request. The Plan 
says the request 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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure device 
(LAAC) (33340). 
 
You asked the Plan to pre-approve placement of a LAAC. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet 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 placement of a LAAC. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found LAAC placement would not 
be considered reasonable or medically necessary in this enrollees clinical management. 
 
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 LAAC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a left atrial appendage closure device (LAAC) (33340).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on December 12, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary and is 
covered. The Plan denied your request. The Plan says this test does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on February 6, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that the enrollee could not choose an in-network 
provider. The Plan denied your request. The Plan says this was not authorized. 
 
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 nursing facility care provided on February 6, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you have seen other providers that are in-
network. The Plan denied your request. The Plan says you must receive your care from a 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 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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is not enough evidence to show that this procedure is safe and that it 
works well for knee pain. Medicare rules state that experimental and investigational devices are not covered. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and radio-frequency ablation of the genicular nerves are the 
subject of ongoing clinical trials and are considered experimental therapy at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty wheelchair (K0006). 
 
You asked the Plan to pre-approve a heavy-duty wheelchair. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a heavy-duty wheelchair. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not weigh 
enough to require a heavy-duty wheelchair.  Additionally, the documentation does not indicate the enrollee is 
unable to use a walker or cane. 
 
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 heavy-duty wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty wheelchair (K0006).