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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861, E2361, E1028, E2377, E2313, E1007, E2620, E0955, E1012, E2607, E0950, E2311). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for tilt and recline features and therefore does not meet criteria for base code power wheelchair group 3 with 
multiple power options. 
 
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 enrollee has a 
personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, 
feeding, grooming and bathing in customary locations within the home. Provided records do not support that 
the enrollee is high risk for skin breakdown (she is currently using a manual wheelchair for mobility and has no 
reported history of pressure ulcer(s) or skin flap surgery). Records do not document the enrollee performs 
bladder self-catheterization and is unable to transfer independently or that she has increased muscle tone or 
spasticity. Thus, she does not meet criteria for power tilt/recline or the multiple power option. 
 
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 with multiple power options (K0861, 
E2361, E1028, E2377, E2313, E1007, E2620, E0955, E1012, E2607, E0950, E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 5, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 procedure code 76705 billed for date of service April 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pregabalin. 
 
You asked the Plan to pre-approve Pregabalin. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pregabalin.  
 
Benefits for Pregabalin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976.  
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 76700 
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 procedure code 76700 billed for date of service May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 27, 2022, to 
March 30, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 27, 2022, to March 30, 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 laboratory services provided on February 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the member has already established care with 
this provider and wishes to continue seeking services for this condition under this physician at this location. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan 
also says that these services were not approved in advance. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service 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 laboratory services provided on February 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry test provided on March 21, 2022. 
 
You asked the Plan to pay for mass spectrometry. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the use of the -59 modifier is not supported for this code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record does not show that this test was a separate and distinct service from the other 
tests performed on this date of service. Based on this information, we decided that Medicare rules for coverage 
of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to 
pay for mass spectrometry test provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) billed on December 22, 2021. 
  You asked the Plan to pay for critical care services (99291). You say that medical records are attached, and the 
claim should be processed accordingly. The Plan denied your request. The Plan says the documentation only 
supports one unit of procedure code 99291, which was paid. 
 
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 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code on December 22, 2021, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of the additional unit of procedure code 99291 have not been met. Therefore, we decided that the 
Plan does not have to pay for critical care services (99291) billed on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted case management provided on February 28, 2022, to 
March 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for targeted case management. You say that a representative from the Plan said that 
services for this procedure code did not require authorizations. The Plan denied your request. The Plan says the 
rendering provider is a non-participating provider. The Plan also says that they did not authorize any services 
for this provider or the facility. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service 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 targeted case management provided on February 
28, 2022, to March 4, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve ablation. 
 
You asked the Plan to pre-approve Intracept intraosseous basivertebral nerve ablation. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept intraosseous basivertebral 
nerve ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was being treated for vertebrogenic low back 
pain. The enrollee presented with worsening low back pain, intermittent left leg pain, and worsening mid-back 
pain. The exam reveals significantly less pain with palpation and segmental mobilization of the lumbosacral region. Segmental mobilization provokes pain in the mid-thoracic region. Strength, sensation, and reflexes are 
intact. The lumbar range of motion is restricted due to low pain radiating to the right greater than left lower 
extremity. Straight leg raise on the left is positive at 45 degrees. Sacroiliac joint provocative maneuvers on the 
left are mildly positive. In this case, there were/are multiple plausible pathologic sources of significant pain 
generation. The radiating midline back pain, along with the diminished and painful spinal motion (in all 
directions) and intact neurologic exam were/are all non-specific to any pathologic entities.  
 
Overall, the documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive 
of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. The documentation does not support actual formal surgical ablation of pre-designated basivertebral 
nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept intraosseous basivertebral nerve ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve 
ablation.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oxygen concentrator (E1390) and a portable gaseous oxygen 
system (E0431). 
 
You asked the Plan to pre-approve an oxygen concentrator and a portable gaseous oxygen system. You say that 
the requested equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says 
that the enrollee has used 36 months of this service as of 05/15/2017. The rental period has capped, and the 
equipment is now purchased/owned. There is no indication or documentation stating replacement items are 
being requested. 
 
The Plan must follow Medicare rules. Medicare rules say at any time after the end of the 5-year reasonable 
useful lifetime for oxygen equipment, the beneficiary may elect to receive new equipment, thus beginning a 
new 36-month rental period.  
 
We looked at the file and Medicare rules. The records show that you received an oxygen concentrator and 
portable oxygen system, on May 15, 2014, through May 15, 2017. The Medicare rules say that any time after 
the reasonable 5-year useful lifetime for oxygen equipment, the enrollee can receive new equipment with a new 
36-month rental period. The records also show that the provider submitted a new referral for new oxygen 
equipment. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator 
and a portable gaseous oxygen system have been met. Therefore, we decided that the Plan has to pre-approve 
an oxygen concentrator (E1390) and a portable gaseous oxygen system (E0431).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will get the needed doctor, 
nurses, treatment and care at the LTACH. The Plan denied your request. The Plan says based on Medicare 
guidelines, the long-term acute care hospital services you are requesting do not meet the requirements for 
approval. 
 
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 was admitted with fever and altered mental status in the setting of lung 
cancer and chemotherapy. The record indicates the enrollee still requires acute care services before 
transitioning to a lower level of care. The medical record does not indicate that the enrollee requires services 
that they are not currently receiving but that would be available at the LTACH facility. 
 
 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized 
and is ready for discharge from the acute care hospital. The Plan denied your request. The Plan says admission 
to LTACH was denied as not meeting criteria, is not medically necessary, and continued acute hospital stay 
was offered, until the member could discharge to a lower level of care. 
 
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 was admitted to the acute care hospital with acute respiratory failure and 
status epilepticus. The enrollee was unresponsive in the field and intubated. Currently on T-tube with 30% 
oxygen.  Continuous electroencephalogram (EEG) monitoring study suggestive of right temporal potential 
epileptogenicity along with right frontotemporal non-specific dysfunction in the setting of severe diffuse 
dysfunction.  The enrollee remains on continuous EEG monitoring and therefore lacks stability for LTACH admission. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a three-month rental of a powered low air loss mattress. 
 You asked the Plan to pre-approve a three-month rental of a powered low air loss mattress. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say a pressure-reducing air mattress is covered when the 
enrollee has multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to improve over 
the past month, or the enrollee has large has multiple stage 2 pressure ulcers located on the trunk or pelvis 
(refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses) which have 
failed to improve over the past month, or the enrollee had a myocutaneous flap or skin graft for a pressure ulcer 
on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior 
to discharge from a hospital or nursing facility within the past 30 days. 
 
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 three month rental of a powered low 
air loss mattress. Our reviewer says that the documentation does not support that the requested item is 
medically reasonable or necessary. Our physician reviewer found the enrollee had one pressure ulcer in the 
middle of the back. The wound is not measured and simply noted as skin breakdown. The enrollee's condition 
must have evidence of progression or failure to respond to treatment or be a large stage three or be associated 
with graft or flap. The documentation does not support that either of those conditions are met. Therefore, the 
enrollee does not meet criteria for the requested item. 
 
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 three-month rental of a powered low air loss mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a three-month rental of a powered low air 
loss mattress.