Persius/hicric huggingface dataset:
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 LTACH is the appropriate level of care 
for the enrollee and he is stable to be transferred to the LTACH. The Plan denied your request. The Plan says 
the enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 is receiving appropriate care at the present acute care hospital. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 pay for electrical stimulator supplies (A4595) billed for date of 
service April 15, 2022. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for electrical stimulator supplies (A4595) billed for date of service 
April 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76857 billed for date of service October 17, 
2022. 
 You asked the Plan to pay for procedure code 76857. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76857 is bundled into payment for 
code 76775. 
 
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, we have confirmed that code 76857 
is a column II code to column I code 76775. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76857 billed for date of service October 17, 
2022.
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 feel that the last facility abused you and did not 
take care of you as they should have, causing you fear for your safety. You don't want to return to a nursing 
home/skilled nursing facility. The Plan denied your request. The Plan says you do not meet criteria for inpatient 
rehabilitation and do not require 3 hours of multidisciplinary skilled therapy per day. 
 
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 you may benefit from physical therapy, and occupational therapy that may safely be 
provided in a lower intensity and alternate setting such as in a skilled nursing 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 pre-approve Hyperbaric Oxygen Therapy. 
 
You asked the Plan to pre-approve Hyperbaric Oxygen Therapy. You say that the enrollee has a diabetic ulcer 
that is a Wagner Grade 3 and has had over 30 days of wound care for the wound. You say the physician feels 
that the patient would benefit from Hyperbaric Oxygen Therapy at this time as Hyperbaric Oxygen Therapy 
has been shown to increase the healing of diabetic foot ulcer wounds. The Plan denied your request. The Plan 
says Hyperbaric Oxygen Therapy is not medically necessary based on the Medicare guidelines. 
 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 Hyperbaric Oxygen Therapy. Our 
reviewer says that Hyperbaric Oxygen Therapy is not medically necessary in this case. Our physician reviewer 
found there was no evidence of infection. The ankle-brachial index (ABI) was low suggesting poor circulation. 
The enrollee also has severe lymphedema further contributing to poor circulation and healing. The records did 
not clearly describe the enrollees diabetes was well controlled with lifestyle and medication therapy. Based on 
the above, the Medicare criteria has not been met and the enrollee is not likely to have much or any benefit 
from Hyperbaric Oxygen Therapy in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyperbaric Oxygen Therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Hyperbaric Oxygen Therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 4, 2022, to May 
14, 2022, at the DRG originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported appropriately and are supported as billed. The Plan denied your request. 
The Plan says the DRG submitted on this claim is not supported in the medical record. 
 
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 N17.0 - kidney failure with tubular necrosis. 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 physician reviewer found there was no clinical or laboratory evidence of acute kidney 
failure due to acute tubular necrosis: urinalysis (UA) with non-hyaline casts (granular or muddy casts or renal 
tubular cells), Urinary sodium greater than 40 mEq/L, FeNA greater than 2%, or renal biopsy confirmation. 
Urine culture showed no white blood cells (WBC), no red blood cells (RBC), no bacteria, and 1-3 squamous 
epithelial cells. The review has determined that the documentation did not support acute kidney failure with 
tubular necrosis (N17.0).  
 
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 May 4, 2022, to May 14, 2022, at the DRG originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
February 2, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360 and 88381. You say that these services were necessary 
and were reported appropriately. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services billed with code 99152 for 
March 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 12, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services billed with code 99152 for March 
2, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that you need treatment. The Plan denied your request. 
The Plan says that the documentation does not support that you have an accepted medical indication for the use 
of Opdivo. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our physician reviewer found 
Opdivo is FDA-approved for adult patients with metastatic non-small cell lung cancer and progression on or 
after platinum-based chemotherapy. Our reviewer also found that the documentation supports that Opdivo is 
expected to be safe and effective and otherwise reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have been met. Therefore, we decided that the Plan has to pre-approve 
Opdivo (J9299).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom breast prosthesis, post mastectomy, molded to 
patient model (L8035). 
 
You asked the Plan to pre-approve a custom breast prosthesis. You say that the enrollee has been wearing a 
custom silicone breast prostheses and is in need of a replacement. The enrollee has not had any reconstruction 
and has had a left breast mastectomy due to breast cancer in 2007. This product works well for the enrollee in 
order to achieve balance and symmetry with her existing right breast. This product is medically necessary for 
the overall well-being of this enrollee. The Plan denied your request. The Plan says this is not a covered item 
for any reason per the LCD and with national consensus. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The LCD confirms that if a breast prosthesis is billed, it will be 
denied as not reasonably and necessary. Based on this information, we decided that Medicare rules for 
coverage of a custom breast prosthesis have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a custom breast prosthesis, post mastectomy, molded to patient model (L8035).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says this item is not covered for the 
enrollee's condition. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 26, 2022, to 
February 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 26, 2022, to 
February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig, any type, each (A9282). 
 
You asked the Plan to pre-approve a wig. You say that your hair is falling out and the wig that you need is not 
covered under durable medical equipment The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig, any type, 
each (A9282).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you would like this item to go 
to medical appointments and to the church. The Plan denied your request. The Plan says this item is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 15, 2021, billed 
with codes 81408, 81249, 81226, 81225, 81306, 81350, 81328, 81335, 81227, 81230, 81231, 81232, 81381, 
81401, 81355, 81241, 81291, 81240 and 81400. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 15, 2021, billed with codes 81408, 81249, 81226, 81225, 81306, 81350, 81328, 81335, 81227, 
81230, 81231, 81232, 81381, 81401, 81355, 81241, 81291, 81240 and 81400.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins 
treated in a single extremity, each through separate access sites; list separately in addition to code for primary 
procedure (36479). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you received the service for the right 
leg and now needs it for the left leg. The Plan denied your request. The Plan says this request is not medically 
necessary as the enrollee had received the treatment on 8/16/22 and the records do not show why the enrollee 
needs to have this again. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not meet coverage criteria and does not support the medical 
necessity of the treatments in question.  Coverage criteria require that the require have significant symptoms 
attributable to the veins in question. The documentation does not demonstrate that the enrollee is having 
symptoms in the left leg severe enough to interfere with daily activities and/or quality of life. The Plan 
articulated by the provider only call for treatment of the right lower extremity (completed). Additionally, there 
is documentation of significant arterial occlusive disease of the right lower extremity. In this setting, the 
elimination of both the enrollees great saphenous veins may not be advisable. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the endovenous ablation therapy of incompetent vein, extremity, inclusive of all 
imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single 
extremity, each through separate access sites; list separately in addition to code for primary procedure (36479).