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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you have used this ventilator daily for two 
years. This endangers your health if you are not able to have the ventilator. You are dependent on the ventilator 
and without it, you will be in complete distress and possibly be hospitalized. The Plan denied your request. The 
Plan says the request for continued use of a non-invasive ventilator (NIV) is not medically necessary because 
the documentation does not support that this device meets but does not exceed your need. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic respiratory failure from obesity hypoventilation syndrome without documentation of thoracic 
restrictive disease. Notwithstanding the fact that the noted condition is not one for which coverage is available 
under the rules, the provided primary source documentation does not contain sufficient detailed information in 
the medical record to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS 
capability and failure of such a device has not been documented. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. The requested service 
cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 chiropractic visits. 
 
You asked the Plan to pre-approve chiropractic visits. You say that you are appealing the denial for 
chiropractic services. The Plan denied your request. The Plan says that medical necessity requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic visits. Our reviewer says 
that the record indicates that the enrollee has lumbar and sacroiliac pain. The records indicate that the enrollee 
has been receiving treatment since December 2021, and that these visits do not support progressive 
improvement of symptoms but rather maintenance therapy. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. Our physician reviewer 
found that the elements of the coverage criteria are not satisfied. The requested service is not 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 chiropractic visits. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 6 chiropractic visits.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transfemoral carotid stent surgery (37215). 
 
You asked the Plan to pre-approve transfemoral carotid stent surgery. You say that the requested procedure is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested procedure is 
not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare covers PTA of the carotid artery concurrent with 
the placement an FDA-approved carotid stent with embolic protection when the criteria listed in the Medicare 
rules section of this letter have been 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 transfemoral carotid stent surgery. Our 
reviewer says that the requested procedure is medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is status post stroke, myocardial infarction (MI) and recent coronary 
intervention. The enrollee satisfies high risk for carotid endarterectomy criteria due to recent MI and, for the 
purpose of this review, greater than 75% stenosis is equivalent to at least 80% stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transfemoral carotid stent surgery have been met. Therefore, we decided that the 
Plan has to pre-approve transfemoral carotid stent surgery (37215).  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the admission to an IRF is not medically 
necessary. 
 
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 that the enrollee does not have complex nursing or rehabilitation needs. 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 the 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental when used as bone graft. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99345, 99354, 99355 rendered on October 
11, 2022. 
 
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 support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99345: 
 
Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the patient is unstable or has developed a significant new problem requiring immediate physician 
attention. Typically, 75 minutes are spent face-to-face with the patient and/or family 
 
CPT 99354: 
 
Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual 
service; first hour (List separately in addition to code for outpatient Evaluation and Management or 
psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 
99213, 99214, 99215]) 
 
CPT 99355: 
 
Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual 
service; each additional 30 minutes (List separately in addition to code for prolonged service) 
 
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 code 99345 is not supported. 
The history documented is not comprehensive. No family history is documented and the enrollee's complete 
medical/surgical history is not documented, nor is a review of systems documented. The medical decision 
making consists of continuing the patient's current regimen with the addition of physical therapy and some 
testing; this would bge considered moderate complexity, not high level. CPT 99354 and 99355 are add on 
codes and require a primary procedure. Since the incorrect primary procedure was reported, a valid primary 
procedure needs to be reported in order to verify how much time beyond the usual service was performed. 
These codes are not supported. 
 
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 procedure codes 99345, 99354, 99355 rendered on October 11, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services (Q5001, G0162, G0151) provided on 
February 21, 2022 to March 17, 2022.  
 
You asked the Plan to pay for home health services. You say that the services should be covered as the 
enrollees disagree with the denial. The Plan denied your request. The Plan says that the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that 
the services are medically reasonable and necessary. Our physician reviewer found that the records include a 
face-to-face visit note indicating necessity of the home health services for disease management, medication 
instruction, gait and balance training, strength, mobility and activity of daily living training and signed orders 
from the enrollees treating physician indicating agreement with and necessity of the home health 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 home health services have been met. Therefore, we decided that the Plan has to 
pay for the home health services (Q5001, G0162, G0151) provided on February 21, 2022 to March 17, 2022.   
 
  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: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not have a medical need for multiple power options included 
with a K0861 group 3 power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are 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 wheelchair. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has both upper and lower extremity weakness with impaired endurance. The enrollee is 
functionally non-ambulatory. The enrollee cannot use a cane or walker for mobility. The enrollee cannot 
functionally propel a manual wheelchair due to weakness and a lack of endurance. The enrollee cannot operate 
a power scooter due to impaired trunk control and weakness. The enrollee is noted to have spasticity, and the 
enrollee's medical condition is progressing downwards rapidly per the clinical progress notes. Given the nature 
of amyotrophic lateral sclerosis (ALS), the enrollee will soon require assistance with all daily activities. The 
enrollee requires a power wheelchair for mobility and performing daily activities and would better suited with a 
Group 3 power wheelchair power tilt and recline and power elevating leg rests for the appropriate positioning 
and her ALS. 
 
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 wheelchair have been met. Therefore, we decided that the Plan has to pre-
approve a group 3 power wheelchair with multiple power options.  
 
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 an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the patient's last ESI was 
performed in 2019 and is documented to have 100% relief for several weeks. Regardless, that injection was 
nearly four years ago and due to the patient's stenosis and disc protrusion it is beyond reasonable to attempt 
another injection. The Plan denied your request. The Plan says the patient does not meet any criteria for the 
requested injection- no clinical or historical indication of nerve or cord compression, no prior injections that 
gave more than 50% pain reduction lasting at least 10-12 weeks, no recent injections. 
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that the enrollee has chronic neck pain of years duration with worsening over the 
last year. The pain is axial in nature without described radicular pain pattern. The enrollee has additional 
complaints of low back pain and joint pains of various locations with a problem list that includes fibromyalgia, 
discoid lupus, polyarthritis and chronic pain syndrome. There is no indication of extremity weakness, 
incontinence or difficulty walking is given or any other red flags. The enrollee had prior cervical ESI x 2 in 
2019 with reported improvement of pain for only a few weeks. The request does not meet the criteria because 
the duration of pain relief of the last injection does not meet the criteria. of three months of 50% relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left atrial appendage exclusion procedure (33269). 
 
You asked the Plan to pre-approve a left atrial appendage exclusion. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 left atrial appendage exclusion. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains an absence of randomized clinical studies examining long-term 
clinical outcomes. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit. As such, guidelines would not support thoracoscopic left atrial appendage exclusion using an AtriClip. 
 
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 left atrial appendage exclusion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a left atrial appendage exclusion procedure (33269).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 You asked the Plan to pre-approve Orencia. You say that due to the enrollee having hematologic malignancy 
the required drugs are not preferred in their specific circumstances. The Plan denied your request. The Plan 
says the step therapy requirements have not been met.  
 
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 Orencia. Our reviewer says that 
Orencia is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
required drugs Remicade, Inflectra, infliximab, Simponi Aria, and Stelara. There is no documentation 
indicating that the Plan's required drugs would likely be less effective 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 Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80305 and 99490 rendered on September 6, 
2022. 
 
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 provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at  the file and Medicare rules. CPT 99490 was billed on the same day at CPT 20552 without an 
appropriate modifier. CPT 20552 has a global surgery period of zero days.  
Additionally, there are no medical records to support that CPT 80305 was rendered in this case. There is just a 
small section marked "UDS results" with a +. There are no progress notes, or a physician order for any drug 
testing. 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 procedure codes 80305 and 99490 rendered 
on September 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22206, 22600, 22614, and 22843 for date of 
service October 25, 2022.  
You asked the Plan to pay for procedure codes 22206, 22600, 22614, and 22843. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 22206, 22600, 22614, and 22843 are not supported in the medical record. Specifically, 
codes 22206 and 22600 are considered part of the global surgical package of the initial 
procedure CPT code 63045 (Laminectomy, facetectomy and foraminotomy). 
In addition, we have confirmed that codes 22614 and 22843 are add-on code sand have not been billed with an 
appropriate primary procedure code. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 22206, 22600, 22614, and 22843 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 22206, 22600, 22614, and 22843 for date of service October 25, 2022.