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

 
We decided that the Plan does not have to pre-approve addition to lower extremity, above knee or knee 
disarticulation, acrylic socket (CPT code L5631) and addition to endoskeletal knee-shin system, fluid stance 
extension, dampening feature, with or without adjustability (L5848). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the advanced knee and acrylic socket are not reasonable and necessary for a preparatory 
prosthesis. 
 
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 items. Our physician reviewer 
found when an above knee initial prosthesis (L5505) or an above knee preparatory (L5560, L5570, L5580, 
L5590, L5595, L5600) prosthesis is provided, prosthetic substitution and/or additions of procedures and 
components are covered in accordance with the functional level assessment except for codes including L5631 
which will be denied as not reasonable and necessary. The enrollee was approved for L5580; therefore, the 
L5631 is not medically necessary. L5848 is covered for patients who are a K3 or above ambulator. The 
enrollee is not a K3 ambulator; therefore, this request exceeds her needs. LCD: Lower Limb Prostheses 
(L33787) criteria have not been met for the requested L5631 and L5848. 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 
items have not been met. Therefore, we decided that the Plan does not have to pre-approve addition to lower 
extremity, above knee or knee disarticulation, acrylic socket (CPT code L5631) and addition to endoskeletal 
knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service September 21, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial indicates that the MUE for procedure code 76641 
is 1 and the MAI value for this code is 2. The Plan states that you billed 2 units of this code, exceeding the 
MUE. However, we find that the code has an MUE of 2. The MUE has not been exceeded in this case. 
 
It is the Plan's responsibility to substantiate its denial. In this case, the Plan's denial has not been substantiated, 
so we must find in your favor. Therefore, we decided that the Plan has to pay for procedure code 76641 billed 
for date of service September 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on April 21, 2022, billed with 
code 11043-59. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that this code is payable with the 
modifier. The Plan denied your request. The Plan says the records do not support separate payment for code 
11043. 
 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 11043 is a column II code to column I code 13152; however, 11043 
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 services as billed. Our reviewer says that the 
documentation does not support the use of modifier -59 to bypass the edit with 13152. Our reviewer found the 
medical documentation does not support the use of the additional closure procedure code. The debridement is 
already extensive as it is down to muscle, which also includes the closure. The documentation does not support 
that the code 11043 is separate and distinct. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on April 21, 2022, billed with code 11043-59.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 3, 2022, to 
May 2, 2022. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the claim 
was not 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 have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from April 3, 2022, to May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara System (E1399x12, A9999x12). 
 
You asked the Plan to pre-approve a Volara System. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says there are no studies showing that the device is 
associated with improved outcomes in bronchiectasis in outpatient setting. Volara is a new system combining 
different therapeutic interventions including lung expansion and chest wall oscillation. There are no published 
studies showing use in bronchiectasis. As a result, the device is considered 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 Volara System. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has primary ciliary dyskinesia and severe COPD, recently hospitalized 
with an exacerbation. The enrollee is unable to use HFCWO for airway clearance because of skin rash. She is 
using a flutter valve, but it is not helping. The Volara system combines airflow oscillation with nebulization 
and positive end-expiratory airway pressure. The airflow oscillation has not been shown to be safe and 
beneficial in the treatment of COPD and bronchiectasis. Nebulization duplicates already approved treatment. 
End-expiratory pressure is of no proven benefit in this enrollee's condition. 
 
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 Volara System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara System (E1399x12, A9999x12).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. You say that the enrollee is being treated for osteoarthritis of 
the hip. You say that the enrollee has tried and failed cortisone injection, Tylenol and anti-inflammatories. You 
also say that the enrollee is scheduled to start physical therapy. The Plan denied your request. The Plan says the 
requested drug is not medically necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Synvisc-One. Our reviewer says that 
the requested drug, Synvisc-One, is not medically necessary. Our physician reviewer found the requested use 
of Synvisc-One is not approved by the Food and Drug Administration (FDA) for the enrollees diagnosis. The 
reviewer found that the requested use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). 
Therefore, the reviewer found that the requested drug is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (J7325).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided to the enrollee from January 8, 2022, to 
February 2, 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 that Medicare rule for payment of these dates was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not submitted a reason for why the admission date of January 8, 
2022 would be inappropriate in this case. This admission date appears to follow the guidelines. Therefore, we 
decided that the Plan has to pay for home health services provided to the enrollee from January 8, 2022, to 
February 2, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service November 4, 
2021. 
 
You asked the Plan to pay for procedure code 88321. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 21, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99140 is considered bundled and not separately payable. 
 
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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thrombolysis (37195) provided on April 16, 2022. 
 
You asked the Plan to pay for thrombolysis 37195. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this code may not be paid if furnished in a hospital inpatient or 
hospital outpatient department. 
 
The Plan must follow Medicare rules. Medicare rules say that code 37195 is not payable when provided to a 
hospital inpatient or patient in a hospital outpatient department.  
 
We looked at the file and Medicare rules. This service was performed in a hospital outpatient setting; therefore, 
it is not payable. Based on this information, we decided that Medicare rules for coverage of thrombolysis 
37195 have not been met. Therefore, we decided that the Plan does not have to pay for thrombolysis (37195) 
provided on April 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-contact real-time fluorescence wound imaging 
(0598T) provided on July 27, 2022. 
 
You asked the Plan to pay for the non-contact real-time fluorescence wound imaging. You say that you believe 
this code was incorrectly denied, as you have found the code is covered and payable by Medicare. The Plan 
denied your request. The Plan says with the information provided, it cannot be determined how the enrollee 
came to the servicing provider, or whether the service was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the non-contact real-time fluorescence 
wound imaging have been met. Specifically, the documentation submitted does not include any clinical 
information. Without this information we are unable to verify the service at issue. Therefore, we decided that 
the Plan does not have to pay for the non-contact real-time fluorescence wound imaging (0598T) provided on 
July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service July 15, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that this service was 
medically necessary. 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) 88341, 88342, and 
88360. 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) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service July 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiographic recording (93243) provided 
on November 11, 2021. 
 
You asked the Plan to pay for the external electrocardiographic recording. The Plan denied your request. The 
Plan says a reconsideration determination was not provided within the required timeframe. 
 
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 external electrocardiographic recording. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there was insufficient support provided in the records to perform this 
monitoring when recent and previous monitoring was already performed and revealed enough information to 
move forward with the workup and treatment plan. Our reviewer also found that there was no documentation 
provided describing the clinical reasoning for this repeated monitoring or how it would lead to an improved 
outcome for this 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 the external electrocardiographic recording have not been met. Therefore, we 
decided that the Plan does not have to pay for the external electrocardiographic recording (93243) provided on 
November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and accessories 
(E2361, E2300, E1002, E0955, E1028, E2607, E1028, E1020). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee does not have 
a medical need for a single power option included with K0856 group 3 power wheelchair and accessories. The 
Plan denied your request. The Plan says the requested wheelchair is medically necessary for the enrollee's 
diagnosis of osteogenesis imperfecta. She is currently using a donated manual wheelchair which is not meeting 
her needs. 
 
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 wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
indicates the enrollee has a mobility deficit that impairs MRADLs in the home. The documentation does not 
reveal that the enrollee uses a ventilator attached to a wheelchair, is at high risk for development of a pressure 
ulcer. There is no evidence of use of intermittent catheterization. The physician documentation does not 
indicate objective evidence of spasticity on a BLE physical exam that needs a power seating system for 
management. The seat elevator is not medically necessary as it does not serve a primary medical purpose and is 
not covered per guidelines. Therefore, the request for group 3 power wheelchair and accessories exceeds the 
enrollee's medical needs. 
 
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 wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and accessories (E2361, 
E2300, E1002, E0955, E1028, E2607, E1028, E1020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on July 8, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the walker from an OON provider. You say that you are diabetic and need the 
walker for stability. The Plan denied your request. The Plan says the walker was purchased from an OON 
provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for the item provided OON. Therefore, we 
decided that the Plan does not have to pay for a walker provided on July 8, 2022, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thread carpal tunnel release. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says surgical remedy of carpal tunnel has well described serious morbidity associated 
with it and should not be offered casually. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the case file contains insufficient documentation of ineffective non-surgical treatment of 
carpal tunnel syndrome 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thread carpal tunnel release.