Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve home health 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
The records do not support that he requires additional skilled rehabilitation services to provide medically 
necessary treatment. He does not require additional skilled rehabilitation services to effectively provide 
treatment, care, and/or services in order to improve his condition, perform a maintenance program to maintain 
the his condition, and/or prevent deterioration. The additional services are not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two additional home health physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the psychotherapy visits provided from 
August 19, 2022, to September 16, 2022. 
 
You asked the Plan to provide reimbursement for the psychotherapy visits. You say that the provider is out-of-
network and does not take insurance at all. The Plan denied your request. The Plan says that the provider does 
not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for the psychotherapy 
visits provided from August 19, 2022, to September 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 9, 2022, to June 
7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 May 9, 2022, to June 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99217 billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code remains 
not supported. 
 
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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status". 
  
 We find that CPT code 99217 is not supported in the medical record. Specifically, the records provided do not 
include discharge day management on the date of service at issue. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99217 billed for date of service May 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 29, 2022, to 
August 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 July 29, 2022, to August 
27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral splint for temporomandibular joint (TMJ) 
dysfunction (21299) provided on October 19, 2022. 
 
You asked the Plan to pay for the dental item. You say that you would like to appeal this denial. The Plan 
denied your request. The Plan says the item at issue in this case is dental in nature. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. The record shows that an oral splint was delivered to the enrollee on the 
date of service in this case. Therefore, we decided that the Plan does not have to pay for the oral splint for 
temporomandibular joint (TMJ) dysfunction (21299) provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vertical shock 
reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve the vertical shock reducing pylon feature. You say that the vertical shock 
pylon (L5988) is not listed, and would be covered as part of a preparatory prosthesis. The Plan denied your 
request. The Plan says a vertical shock reducing pylon feature is requested does not meet Medicare criteria as 
reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
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 vertical shock reducing pylon 
feature. Our reviewer says that there is no documentation that the special prosthetic part (vertical shock pylon) 
meets the requirements listed in the LCD for Medicare coverage. Our physician reviewer found the provided 
records from the treating physician and the prosthetist do not support necessity of the vertical shock pylon. The 
enrollee is reported to have the potential for K2 ambulation for "cooking, cleaning and laundry" and 
negotiating "curbs, stairs and uneven surfaces." Our reviewer also found that the records do not support that the 
enrollee's activity is anticipated to be of such a vigorous nature as to require a vertical shock pylon at this time. 
 
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 vertical shock reducing pylon feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vertical shock reducing 
pylon feature (L5988).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) administered on August 18, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global 
surgery payment for the procedure (64493) provided on the same date. Based on this information, we decided 
that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan does not 
have to pay for the drugs (J3490) administered on August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service March 8, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services were 
reported correctly. The Plan denied your request. The Plan says these services are not supported for separate 
payment, as they are included in code 87801. 
 
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 codes 87481 and 87653 are column II codes to column I code 87801. 
These services have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met for codes 87481 and 87653. In addition, we have 
confirmed that code 87798 is a column II code to column I code 87801; however, 87798 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 procedure code 87798. Our reviewer says that the use of the 
91 modifier is not supported in this case. Our reviewer found the laboratory does not report multiple serial 
laboratory tests. Therefore, CPT code 87798 would be included in CPT code 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a stance flexion feature (L5845). 
 
You asked the Plan to pre-approve the services. You say that this would provide a tremendous benefit to the 
patient. The Plan denied your request. The Plan says that although the vendor uses code L5845 for this knee, 
neither the manufacturer nor the vendor has the authority to assign this code to the requested knee. 
 
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. A review of the Pricing, Data Analysis and Coding (PDAC) does not indicate 
that the plan has forwarded a valid denial for this case. There is only one entry for an item that contains L5822, 
and it's a Pneumatic Single Axis Knee With Weight Activated Lock. This is not provided by the same company 
that is requesting the item in this case. This is not the same item that is being requested in this case. The plan 
cannot base their denial on this information. Therefore, we decided that the Plan has to pre-approve a stance 
flexion feature (L5845).  
 
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 use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that positive airway pressure (PAP) with backup rate 
was tried and failed. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for 
this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at 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 use 
of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medial branch block (MBB) at a third level (64492). 
 
You asked the Plan to pre-approve the MBB. You say that this is the best course of action for the enrollee's 
pain symptoms. The Plan denied your request. The Plan says an injection at a third level is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that the need for a three or four-level procedure bilaterally 
may be considered under unique circumstances and with sufficient documentation of medical necessity on 
appeal. 
 
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 MBB. Our reviewer says that an 
MBB at a third level is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate a unique circumstance described which indicates a need to exceed utilization guidelines. 
Therefore, the reviewer found that an MBB at a third level is 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 MBB have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a medial branch block (MBB) at a third level (64492).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the entire interdisciplinary discharge 
planning team is requesting reconsideration of the denial for LTACH services. The Plan denied your request. 
The Plan says criteria for admission to the LTACH have not been met. 
 
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 stabilizing and should only require short-
term additional acute care hospital services that can safely be provided at the current facility until more stable 
and appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pre-approve complete replacement of an expandable controller 
(E2376) wheelchair component or accessory, not otherwise specified, electronic assy egg Switch black light 
dual lock (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that it is most cost effective to repair vs 
replace. This is the first repair. Please review the attached documentation for medical necessity. 
 The Plan denied your request. The Plan says that an expandable controller and egg switch were not approved 
and therefore repairs cannot be requested on an item that was never approved. 
 
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 upgraded electronics. 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 traumatic brain injury, weakness, and spasticity of his left hand. He 
independent in toileting, dressing, clothing management and hygiene. The requested accessories are not 
medically necessary as he has adequate strength and range of motion to manage standard switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve complete replacement of an expandable controller (E2376) wheelchair component 
or accessory, not otherwise specified, electronic assy egg Switch black light dual lock (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hyaluronic injection in the shoulder. 
 
You asked the Plan to pre-approve hyaluronic injection. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this is not indicated for use in the shoulder. 
 
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 hyaluronic injection. Our reviewer says 
that the enrollee does not meet criteria for hyaluronic injection. Our physician reviewer found in the case of this 
enrollee, they have shoulder osteoarthritis which is not a covered indication for hyaluronic acid injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyaluronic injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a hyaluronic injection in the shoulder.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services requested 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a computed tomography (CT) scan. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the medical necessity 
of the requested CT of the thorax has not been established in the submitted records. 
 
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 computed tomography (CT) scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, 87801, and 
87641 billed for date of service April 4, 2022. 
 
You asked the Plan to pay for procedure code 87150, 87481, 87653, 87798, 87801, and 87641. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for code 87150, 
87481, 87653, 87798, 87801, and 87641 is bundled into payment for codes 87500 and 87150. 
 
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 87150, 
is a column II code to column I code 87500.  Codes 87481, 87653, 87798, 87801, and 87641 are column II 
codes to column I code 87150. 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 codes 87150, 87481, 87653, 87798, 87801, and 87641 billed for date of 
service April 4, 2022.