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

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
a power scooter is not medically reasonable and necessary in this case. Our physician reviewer found that the 
clinical documentation states that the enrollee uses a walker for community distance ambulation and is able to 
climb of flight of stairs. Thus, a power scooter would not be medically unnecessary. 
 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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on January 5, 
2022. 
  You asked the Plan to pay for hot or cold packs therapy (97010). You say that the claim was denied for no 
authorization, but there is authorization on file for this date of service. The Plan denied your request. The Plan 
says CPT codes 97530, 97112, 97110, G0283 have been overturned. The Plan also says CPT code 97010 
remains denied as bundled services are not eligible for separate reimbursement. 
 
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 code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy (97010) have not been met. Therefore, we decided that the Plan does not have to 
pay for hot or cold packs therapy (97010) provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 23, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 6, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic agent injection (64418) provided on 
September 17, 2021. 
  You asked the Plan to pay for the anesthetic agent injection (64418). You say that the attached records should 
be reviewed. The Plan denied your request. The Plan says the documentation does not support the procedure 
was separate or distinct from other services performed. 
 
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 64418 is a column II code to column I code 01844; however, 64418 
was billed with a modifier.  
 
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 anesthetic agent injection (64418). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that in this case CPT code 64418 would be inclusive to the anesthesia service reported. 
 
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 anesthetic agent injection (64418) have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthetic agent injection (64418) provided on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the craniectomy or craniotomy (61315) provided on 
September 16, 2021. 
 
You asked the Plan to pay for the craniectomy or craniotomy (61315). You say that the Waiver of Liability 
form along with medical records are attached to support the necessity to perform a redo-craniectomy. You say 
that the claim should be reviewed and reprocessed for reimbursement. The Plan denied your request. The Plan 
says procedure code 61315-78 is not supported by the medical records submitted. 
 
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 61315 is craniectomy or craniotomy for evacuation of 
hematoma, infratentorial; intracerebellar. 
  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 craniectomy or craniotomy (61315). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the operative report does not include enough documentation to confirm craniectomy or craniotomy 
for evacuation was performed. Therefore, this procedure 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 craniectomy or craniotomy (61315) have not been met. Therefore, we 
decided that the Plan does not have to pay for the craniectomy or craniotomy (61315) provided on September 
16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the device. 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro is not known to be effective, based on scientific evidence, professional standards and 
expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
  
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro orthotic device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
March 30, 2020, through March 31, 2020, billed with code KDXF1. 
 
You asked the Plan to pay for the SNF care as billed. You say that this is coded correctly based on the 
assessments performed. The Plan denied your request. The Plan says since the reported oral hygiene and 
toileting hygiene functional scores are not supported, the therapy and nursing case-mix was correctly adjusted 
from what was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for SNF services is based on a HIPPS 
code with five case-mix groups which are assigned based on the information from the MDS assessment. The 
rules say that for reporting functional abilities in Section GG, facilities must assess self-care performance based 
on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or 
family documented in the residents medical record during the three-day assessment period. It is expected that 
an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three-day 
assessment period. The scores in this section affect both the therapy and nursing case-mix grouping. 
 
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 SNF care as billed. Our reviewer says 
that the reported functional levels on the MDS assessment are not supported by the records provided. Our 
physician reviewer found the enrollee is a 96-year-old woman with a diagnosis of pancreatic cancer, who 
received SNF services. The enrollee was admitted to the skilled facility on March 29, 2020, and had a 5-day 
MDS assessment dated April 04, 2020. The documentation does not sufficiently support functional levels for 
oral hygiene of level 5, and toileting hygiene of level 3. The categories hygiene and toileting do not identify the 
specific self-care and mobility activity and cannot be used to support MDS coding. 
 
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 SNF care as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) services provided from March 30, 2020, through 
March 31, 2020, billed with code KDXF1.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the somatosensory evoked potentials (SSEP) studies provided during a 
procedure on May 27, 2021, billed with code 95938. 
 
You asked the Plan to pay for the SSEP studies. You say that this is medically necessary monitoring and should 
be paid. The Plan denied your request. The Plan says that SSEP studies are not covered for the reported 
diagnosis. 
 
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 pay for the SSEP studies. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee underwent a carotid endarterectomy procedure. The surgeon ordered intraoperative 
monitoring services for the procedure. The use of SSEP monitoring during such a procedure is now considered 
to be a standard of care. SSEPs have been shown to be valuable in both real time monitoring and for prevention 
of post-procedural complications. In as much it can be said that the services provided would have satisfied the 
Medicare definition of medical necessity. 
 
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 SSEP studies have been met. Therefore, we decided that the Plan has to pay 
for the somatosensory evoked potentials (SSEP) studies provided during a procedure on May 27, 2021, billed 
with code 95938.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need a hip replacement, and you are 
being referred to a specialist that is 75 miles away from your home. You also say the Plan advised you would 
need approval of a mileage increase to your appointments. The Plan denied your request. The Plan says you are 
requesting an additional 25 miles for a total of 75 miles and your benefit only allows 50 miles. The Plan also 
says you have exceeded your benefit limit. 
 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 36 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from May 26, 2021, to June 3, 2021. 
 
You asked the Plan to pay for the IRF care. The Plan denied your request. The Plan says IRF care was 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 pay for the 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 did not require the intensity of services provided in an IRF. 
Specifically, the enrollee is not shown to have been able to tolerate fifteen hours per week of rehabilitative 
services with regular physician evaluation.  The enrollees care needs could have been met at a lower 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 the IRF care have not been met. Therefore, we decided that the Plan does not 
have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from May 26, 
2021, to June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography (CPT code 93355) provided on 
January 19, 2022. 
 
You asked the Plan to pay for the echocardiography. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered 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. In this case, we have confirmed that code 93355 
is a column II code to column I code 01926 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the echocardiography (CPT code 93355) provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the seat lift mechanism rendered on May 6, 2021. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the clinical documentation states that the 
enrollee had severe arthritis of bilateral hips after hip replacement surgery and was unable to perform sit to 
stand transfers unassisted. She was able to ambulate household distance. The records support that the criteria 
for coverage are met and the seat lift mechanism was reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the seat lift mechanism rendered on May 6, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs device was approved 
by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary 
artery to allow measurement of pulmonary artery pressure in the management of patients with CHF. The 
clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope.  
 
 
 In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure system.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental cleaning (D1110) and the periodic oral evaluation (D0120) 
provided on March 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services provided do not meet criteria 
for coverage. 
 
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. Specifically, the Plan has not provided the Evidence of Coverage (EOC) contract 
for the year 2022, when the services were provided. The Plan has not substantiated their denial. Therefore, we 
decided that the Plan has to pay for the dental cleaning (D1110) and the periodic oral evaluation (D0120) 
provided on March 8, 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.