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

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377) and harness for upgrade to 
expandable controller, including all fasteners, connectors and mounting hardware, each (E2313). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not 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 the DME. Our physician reviewer 
found provided medical records document the need for an attendant control; with an attendant control, a 
beneficiary-operated drive control system is not covered. There are no indications that the enrollee's caregivers 
cannot operate the power wheelchair options with their own switches. "If an attendant control (E2331) is 
provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. You can 
find this information in Medicare's Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504)." Also, provided records document that the enrollee has 3/5 upper extremity strength and is 
independent with dressing feeding and hygiene, thus indicating he would have adequate upper extremity 
strength and function to operate the wheelchair's power options with their own switches if it were not for the 
attendant control. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade 
provided at initial issue (CPT code E2377) and harness for upgrade to expandable controller, including all 
fasteners, connectors and mounting hardware, each (E2313).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 22899 billed for May 19, 2022. 
 
You asked the Plan to pay for code 22899. The Plan denied your request. The Plan says the billed code is 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 22899 is "Unlisted procedure, spine". 
 
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 code 22899. Our reviewer says that the use of code 22899 is 
not supported by the records provided. Our reviewer found that the operative report documents a non-
segmental percutaneous instrumented fixation L5 to iliac, bilateral transpedicular cement augmentation of L5 
vertebra was performed. The operative report does include documentation of an unlisted procedure.  However, 
an unlisted procedure was not found in the documentation. Services should be reported to the highest 
specificity, and in this case, a more appropriate code should be reported for service provided. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 22899 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 22899 billed for May 19, 2022.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
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 that the documentation does not support that the enrollee has a need for complex 
medical treatment in a LTACH. The enrollee does not require services at the LTACH that are not available at 
the acute care hospital or the skilled nursing facility. The enrollee has improved medically and can receive 
further care at the current acute care hospital or a lower level of care when deemed 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need acute rehabilitation so you can return home 
to independence. The Plan denied your request. The Plan says the criteria for IRF care are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a fall, urinary tract infection and encephalopathy. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you recently had an operation and need to be 
admitted to an inpatient rehab to rebuild strength. The Plan denied your request. The Plan says the Inpatient 
Rehabilitation Facility (IRF) services being requested do not meet the requirements for approval. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine 5% patch. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this drug is for self-administration and is not covered under Medicare Part B. 
 
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 Lidocaine 5% patch.  
 Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myopro orthosis (L8702). 
 
You asked the Plan to pre-approve a Myopro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
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 Myopro orthosis. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
patient or that this device will increase participation in bimanual activities. 
 
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 Myopro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Myopro orthosis (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic analysis of BRCA 1 and 2. 
 You asked the Plan to pre-approve the BRCA genetic testing. You say that it is felt that this is necessary due to 
family history and the risk of cancer. The Plan denied your request. The Plan says this is not covered for 
someone with no personal history of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
This testing is considered screening because it is being ordered in the absence of signs or symptoms of cancer. 
The enrollee has no personal history of cancer, and this is being requested solely due to family history. 
Therefore, we decided that the Plan does not have to pre-approve genetic analysis of BRCA 1 and 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided from 
May 14, 2022, to April 6, 2022. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says payment is included in the 
facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services 
under the Inpatient Prospective Payment System (PPS). These amounts are, with certain exceptions, payment in 
full to the hospital for inpatient operating costs. All items and non-physician services furnished to inpatients 
must be furnished directly by the hospital or billed through the hospital under arrangements. This provision 
applies to all hospitals, regardless of whether they are subject to PPS.  
 
We looked at the file and Medicare rules. Payment for the requested PCD is included in the facility payment. 
Separate payment cannot made for the PCD. Based on this information, we decided that Medicare rules for coverage of the PCD have not been met. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device (PCD) provided from May 14, 2022, to April 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation in order to continue 
to improve your mobility to allow you to live independently. The Plan denied your request. The Plan says the 
IRF care is not medically necessary, and your needs can be met at a lower level of care such as a skilled 
nursing facility, and home with home health services 
 
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 you were admitted to the hospital after a fall at home resulting in dehydration and 
rhabdomyolysis. You were also noted to have acute metabolic encephalopathy and metabolic acidosis. You do 
not require the intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation 
setting. You do not require rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, 
tracheostomy management or neurogenic bowel and bladder management. Your medical and rehabilitation 
needs do not require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (CPT code J7318). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from your prescriber that shows you have tried one of the 
preferred drugs (Monovisc, Orthovisc, Synvisc or Synvisc One), or that you have medical reasons that prevent 
you from using one of them. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the Plan requires a trial of drug Monovisc, Orthovisc, Synvisc or Synvisc One before they will approve 
the requested drug. You have not tried and failed the required drug(s). The documentation does not support that 
Monovisc, Orthovisc, Synvisc or Synvisc-One would likely be less effective, and/or would likely have adverse 
effects for you 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Durolane (CPT code J7318).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (70450, 70496, 71045, 72170, 73020, 
73080, 73100 and 73560) provided on September 5, 2022. 
 
You asked the Plan to pay for imaging services. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 6, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for imaging services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (70450, 70496, 71045, 72170, 
73020, 73080, 73100 and 73560) provided on September 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for inpatient hospital services provided 
from April 12, 2022, to April 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay an additional amount for the inpatient hospital services at the DRG originally billed. 
You say that the documentation supports this diagnosis code. The Plan denied your request. The Plan says the 
provided documentation does not support the billing of diagnosis code, E43. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code, E43, defined as unspecified sever 
protein-calorie malnutrition. 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 an additional amount 
for the inpatient hospital services at the DRG originally billed. Our reviewer says that the billing of diagnosis 
code E43 is not supported. Our physician reviewer found the provided documentation does not indicate any 
clinical support of a severe level of malnutrition. The reviewer found there was no documentation of muscle 
wasting or a body mass index (BMI) indicating the enrollee was underweight. Therefore, the reviewer found 
that the billing of diagnosis code E43 was not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
an additional amount for inpatient hospital services provided from April 12, 2022, to April 25, 2022, at the 
Diagnosis Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), a harness (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that additional clinical information 
submitted to justify the enrollee's need for the power wheelchair and accessories. The Plan denied your request. 
The Plan says although there are two approved power options on this wheelchair, there is not a medical need to 
control these power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided records document that the enrollee has 3-/5 right upper extremity strength 
with no reported deficiency in right hand function or range of motion. Records do not show that the enrollee 
has inadequate right upper extremity strength or function to operate the wheelchair's power options with their 
own switches as required by Medicare criteria for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electrical connection between the wheelchair controller and two or more 
motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 14th unit of procedure code 11045 billed for date of service 
February 14, 2022. 
 
You asked the Plan to pay for a 14th unit of procedure code 11045. You say that you have provided records to 
support the services billed. The Plan denied your request. The Plan says the available records do not support a 
14th unit of procedure code 11045. 
 
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 11045 is: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to 
code for primary procedure). 
 
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 a 14th unit of procedure code 11045. Our reviewer says that 
the service at issue does not meet criteria for payment. Our reviewer found that the 14th unit of the procedure 
code at issue in this case is not supported in the procedure report, as the first 20 centimeters of debridement was 
reimbursed in the primary code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a 14th unit of procedure code 11045 have not been met. Therefore, we decided 
that the Plan does not have to pay for a 14th unit of procedure code 11045 billed for date of service February 
14, 2022.