Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has been billed with an 
inappropriate 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 laboratory 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 laboratory services provided on February 8, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for surgical repair of a hip fracture and non-operative management of a lumbar compression fracture 
after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. 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 you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (CPT code 33285). 
 
You asked the Plan to pre-approve the service. You say that your heart monitor was not approved, and your 
doctor said you need it badly to monitor your heart. You state that you have had strokes and are nervous to 
have another one; however, this heart monitor will make you feel safer. The Plan denied your request. The Plan 
says your request is not medically necessary because your records show there is not a question as to whether or 
not you have paroxysmal atrial fibrillation. The Plan states your doctor does not indicate that the loop 
monitoring test results would impact your medical management. 
 
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 service. Our physician reviewer 
found at issue is whether the requested authorization for placement of an implantable loop recorder (ILR) is 
medically necessary. While the enrollee has a history of atrial fibrillation, with chronic anticoagulation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other 
apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 
33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair (K0005). 
 
You asked the Plan to pre-approve an ultra lightweight manual wheelchair. You say that the requested item is a 
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the 
requested item 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 an ultra lightweight manual wheelchair. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that you had a physical therapist evaluation on December 13, 2021, that 
documented the need for a manual wheelchair K0001 which was approved on January 11, 2022. The 
documentation did not indicate that you require individualized fitting and adjustments for one or more features 
such as, but not limited to, axle configuration, wheel camber, or seat and back angles, which cannot be 
accommodated by a K0001 through K0004 manual wheelchair. 
 
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 ultra lightweight manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair (K0005).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a destruction of benign lesions (17111). 
 
You asked the Plan to pre-approve a destruction of benign lesions. You say that the requested procedure is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules have 
not been met because the requested procedure is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 destruction of benign lesions. Our 
reviewer says that the procedure at issue is not medically reasonable and necessary in this case. Our reviewer found that the procedure serves only a cosmetic purpose. 
 
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 destruction of benign lesions have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a destruction of benign lesions (17111).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 
64483). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records do not show 
documentation of at least 50% sustained improvement in pain for at least three (3) months duration. The Plan 
states the enrollee's records indicate that pain relief only lasted one month and the submitted medical record 
does not describe how this second ESI would be different than the enrollee's prior failed injection. 
 
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 service. Our physician reviewer 
found the LCD criteria is 50% pain relief for 3 months after the injection. This was not achieved and therefore, 
the request is considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you require augmented targeted tidal volume non-
invasive ventilation which cannot be done with a positive airway pressure (PAP) device. The Plan denied your 
request. The Plan says the denial of authorization for this device is correct, because a ventilator is not covered 
by Medicare for this purpose and you could be treated by a bi-level positive airway pressure (BiPAP) device 
with average volume assured pressure support (AVAPS) mode instead. 
 
The Plan follows Medicare rules. Medicare rules state that ventilators may only be covered for certain specific 
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 ventilator. Our reviewer says that you 
do not meet the Medicare criteria for the requested ventilator. Our physician reviewer found you do not have a 
diagnosis for which Medicare covers a home ventilator. You have obstructive sleep apnea (OSA) and 
hypoventilation syndrome. The appropriate treatment for this is continuous or bi-level positive airway pressure 
(CPAP or BiPAP), but you have not tried a BiPAP device at home.  A sleep study may be necessary to determine the appropriate PAP therapy settings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited abdominal ultrasound (76705) provided on 
December 6, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 the limited abdominal ultrasound (76705) provided on December 
6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on September 
20, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
these services were provided to the enrollee in good faith. The Plan denied your request. The Plan says there 
was no documentation of contact with the enrollee's physician in the record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
(90834) provided on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on September 24, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT ode 88360 was billed with code 88361. We find that CPT code 88360 may be eligible 
for payment when billed with this code pair. The claim, however, does not show that the code at issue was 
billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the pathology services provided on September 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation, stab phlebectomy, and 
sclerotherapy. 
 
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 varicose vein treatments are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has been asymptomatic 
with respect to his long-standing varicose veins. He presented with a tender area on his left thigh, that raised 
the concern this might represent a clot and the patient was referred for venous evaluation. At that evaluation the 
clot/area of interest is not specifically investigated. The greater saphenous veins, while reflux was noted, are 
relatively small. There is no documentation that the symptoms are interfering with the enrollees daily activities 
and it does not appear that there was a plan to reassess the enrollee after he used the newly prescribed 
compression stockings. Edema is described as trace. The requested procedures do not meet the criteria for 
coverage and are not 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation, stab phlebectomy, and sclerotherapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography, limited study (95870) provided on 
October 18, 2021. 
 
You asked the Plan to pay for needle electromyography. You say that these services were necessary and were 
billed appropriately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 95867 and 95870. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed as required by Medicare coding regulations. 
 
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 95870 
is a column II code to column I code 95867. 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 needle electromyography, limited study (95870) provided on 
October 18, 2021.
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 the clinical information provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have not been met. The Plan says that the enrollee's needs may be met in the current hospital 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and more stable and should only require short-
term additional acute care services that can be safely administered at the current facility until stable enough for 
a lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. Transfer to an LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Transfer to a lower level of care may be considered when treatment has completed.  
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 the oral device provided on January 26, 2021. 
 
You asked the Plan to pay for the provided services. You say that the provider has done business with the Plan 
on numerous occasions. The Plan denied your request. The Plan says they will only cover the device from 
approved certified suppliers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that that you receive your care from a provider who is eligible to provider services under Original 
Medicare. 
 
The requested provider in this case is not a network provider with the Plan. The records for Centers for 
Medicare and Medicaid Services do not show that the provider at issue is currently a valid supplier for durable 
medical equipment. The Plan did not pre-approve the item 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 the oral 
device provided on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery. 
 
You asked the Plan to pre-approve backup battery. You say that your home has frequent power outages. The 
Plan denied your request. The Plan says this item is not covered by Medicare, because alternate power sources 
are not primarily medical in nature and would be useful to a person in the absence of illness or injury. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery.