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

 
We decided that the Plan does not have to pay for a knee orthosis (L1851) and suspension sleeve (L2397) 
billed for date of service July 7, 2022. 
 
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the available medical records do not address the items at issue. Therefore, we decided 
that the Plan does not have to pay for a knee orthosis (L1851) and suspension sleeve (L2397) billed for date of 
service July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on August 15, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99291 is a critical care visit, first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
detail how much time was spent on this service. Based on this information, we decided that Medicare rules for 
coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care services (99291) provided on August 15, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT of the abdomen. We decided that the Plan does not have to 
pre-approve a CT of the pelvis.  
 
You asked the Plan to pre-approve a computed tomography (CT) of the abdomen and pelvis. The Plan says that 
the requested abdominal and pelvic CT scan is not medically necessary. 
 
  We decided that the Plan has to pre-approve a CT of the abdomen.  
 
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 CT of the abdomen. Our reviewer 
says that a CT of the abdomen is reasonable and necessary. Our physician reviewer found the enrollee has 
persistent epigastric pressure but negative chest x-ray on August 23, 2022, and negative physical exam of the 
abdomen. The epigastric pressure is cause for clinical concern and imaging for same is reasonable. Our 
reviewer also found that this symptom is best evaluated by CT scan, so the requested CT of the abdomen is 
reasonable and should be approved to evaluate the upper abdominal cavity. 
 
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 CT of the abdomen have been met. Therefore, we decided that the Plan has to 
pre-approve a CT of the abdomen.  
 
We also decided that the Plan does not have to pre-approve a CT of the pelvis. 
 
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 CT of the pelvis. Our reviewer says 
that a CT of the pelvis is not reasonable and necessary. Our physician reviewer found there are no clinical 
symptoms whatsoever referrable to the pelvis, so at this time, there is no clinical indication to include the pelvis 
in the evaluation. 
 
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 CT of the pelvis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a CT of the pelvis. 
 
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: Favorable

 
We decided that the Plan has to pre-approve a percutaneous laminotomy/laminectomy (0275T). 
 
You asked the Plan to pre-approve percutaneous laminotomy/laminectomy. You say that this is the best 
treatment option for the enrollee. The Plan denied your request. The Plan says that the requested procedure is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 percutaneous 
laminotomy/laminectomy. Our reviewer says that the requested percutaneous laminotomy/laminectomy is 
considered medically reasonable and necessary in this case. Our physician reviewer found the requested service 
is safe and relieves lumbar spinal stenosis symptoms at up to one-year follow-up. The reviewer found that 
evidence from additional studies suggests that the procedure may be as effective but safer than laminectomy 
and may be more effective than epidural steroid injections. The reviewer found that the enrollee is enrolled in a 
clinical study under section 1862(a)(1)(E) through Coverage with Evidence Development that meets the 
coverage criteria. Therefore, the reviewer found that Medicare coverage for the requested procedure is 
appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous laminotomy/laminectomy have been met. Therefore, we decided 
that the Plan has to pre-approve a percutaneous laminotomy/laminectomy (0275T).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial of admission to a SNF. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing or therapy needs. The 
enrollee's care needs can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenetic testing and for genetic testing for 
cardiovascular disease provided on March 1, 2022. 
 
You asked the Plan to pay for pharmacogenetic testing and for genetic testing for cardiovascular disease. You 
say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan 
says the services at issue have not been established to be 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 pay for pharmacogenetic testing and for genetic 
testing for cardiovascular disease. Our reviewer says that the services at issue are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there are no provided records from the 
enrollee's treating provider in the enrollee's home state which clarify why the testing at issue is needed and 
what role it will play in the enrollee's health 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 pharmacogenetic testing and for genetic testing for cardiovascular disease have 
not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenetic testing and for 
genetic testing for cardiovascular disease provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous durable medical equipment (Q0508) billed for 
date of service May 31, 2022. 
 
You asked the Plan to pay for miscellaneous durable medical equipment. You say that the item at issue was 
billed correctly. The Plan denied your request. The Plan says rules for payment for durable medical equipment 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that miscellaneous durable medical equipment was used in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pay for miscellaneous durable medical equipment (Q0508) billed for 
date of service May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had a hip replacement and has not 
walked for two months, IRF services are needed. The Plan denied your request. The Plan says the request is 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 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9502 billed for date of service March 17, 
2022, to March 20, 2022. 
 
You asked the Plan to pay for procedure code S9502. You say that this is a valid code. The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9502 is not valid for Medicare purposes. 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 procedure code S9502 billed for date of service March 17, 2022, to March 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six or more home health skilled nursing visits. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was instructed on current 
medications without any concerns listed or change in medical status. The records do not support that the 
enrollee requires assessment by skilled nursing. The additional visits are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six or more home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography (75726 and 75774) provided on April 9, 
2022. 
 
You asked the Plan to pay for the angiography (75726 and 75774). You say that it is appropriate to bill 75726, 
75774 and 37244 together when medically necessary. You say that the procedures were separately performed, 
and the claim should be reprocessed for payment. The Plan denied your request. The Plan says procedure codes 
75726 and 75774 are considered inclusive to procedure code 37244.  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 75726 and 75774 are column II codes to column I code 37244; 
however, 75726 and 75774 were 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 angiography (75726 and 75774). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the medical record includes documentation of a visceral angiography, however an intervention was 
performed and reported with procedure code 37244. The medical record also includes documentation of 
additional vessel, angiography, however the intervention performed would include operative angiograms or 
venograms. Therefore, procedure code 75726 is considered inclusive to procedure code 37244 and procedure 
code 75774 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 angiography (75726 and 75774) have not been met. Therefore, we decided 
that the Plan does not have to pay for the angiography (75726 and 75774) provided on April 9, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and 
contents (72141). 
 
You asked the Plan to pre-approve an MRI of the spinal canal and contents. The Plan denied your request. The 
Plan says that the records do not show documentation of physical exam results that included a detailed nervous 
system exam that supports imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the spinal canal and 
contents. Our reviewer says that an MRI of the spinal canal and contents is reasonable and necessary. Our 
physician reviewer found you have continued pain and right radicular symptoms but no neurological deficit. 
You have had a physical therapy evaluation and have done home exercise program. Our reviewer found that 
there were degenerative changes on x-ray. Our physician reviewer also found that due to the above, you have 
met the criteria necessary for an MRI cervical spine. 
 
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 MRI of the spinal canal and contents have been met. Therefore, we decided 
that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and contents (72141).  
 
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 pay for supply allowance used with a therapeutic CGM device 
(K0553) provided April 9, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that your company provides the Freestyle Libre 
device, and it was prescribed to the enrollee by their primary doctor to continuously monitor their blood 
glucose. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM supplies have not been met. Specifically, the documentation submitted does not include a valid signature from the persons responsible for the care of the beneficiary. the Plan made outreach to the 
ordering provider's office and confirmed that the provider indicated did not order the items for this enrollee. 
Therefore, we decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM 
device (K0553) provided April 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee. 
 
You asked the Plan to pre-approve these services. You say that [Enter appellant's argument from appeal letter, 
e.g. "...you need SNF care."] The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. 
"...rules for SNF care 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found [state the medical finding(s) upon 
which the physician based his/her conclusion] 
 
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 K3 microprocessor knee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Irinotecan injections (J9206) provided from May 26, 2022, to July 
7, 2022. 
 
You asked the Plan to pay for the Irinotecan injections. The Plan denied your request. The Plan says that there 
are other choices for second line. The Plan also says that the enrollee is improving on therapy, and there is a 
new lesion on the liver, but data does not support that Irinotecan will help with this alone. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Irinotecan injections. Our reviewer says 
that the Irinotecan injections were medically reasonable and necessary. Our physician reviewer found you have 
a diagnosis of metastatic small cell lung cancer. The use of Irinotecan injections is supported by the National 
Comprehensive Cancer Network (NCCN) Guidelines as an Other Recommended Regimens for subsequent 
systemic therapy for small cell lung cancer. Our reviewer also found that the documentation supports that 
Irinotecan was reasonably expected to be safe and effective and otherwise reasonable and necessary 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 Irinotecan injections have been met. Therefore, we decided that the Plan has 
to pay for the Irinotecan injections (J9206) provided from May 26, 2022, to July 7, 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.