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

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee for a lower limb prosthesis. 
 
You asked the Plan to pre-approve microprocessor knee. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the record does not show why a mechanical knee could 
not be used for the enrollee's prosthesis. 
 
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 microprocessor knee. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested microprocessor need exceeds the enrollee's medical need as it has 
deluxe features that are not medically necessary. There are 19 programmable modes on the requested device 
including a golf mode which does not serve a primarily medical need. The documentation does not support 
why the enrollee is unable to use a mechanical knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a K3 microprocessor knee for a lower limb prosthesis.
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 the enrollee needs acute rehabilitation. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 enrollee is medically stable and does not need rehabilitation physician 
supervision 3 times per week. While the enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation needs can be met in a lower intensity setting such as a skilled nursing 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 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 pay for the inpatient hospital services provided from January 26, 
2021, to January 28, 2021. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says the claim 
processed and paid correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
 We looked at the file and Medicare rules. You have been asked to pay a $185 copay for the services provided. 
The services fall within the inpatient hospital care benefit category. The file shows that the Plan recouped an 
amount from the provider, which is now being charged to you. In this case, the Plan is not responsible for 
paying the balance that remains after the Medicare allowed payment. There is no balance billing paid by either 
the Plan or you. Therefore, we decided that the Plan does not have to further pay for the inpatient hospital 
services provided from January 26, 2021, to January 28, 2021.  
 
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal fusion. 
 
You asked the Plan to pre-approve the spinal fusion. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal fusion should only be considered as a last step 
in the treatment of chronic back pain and is not indicated for most persons suffering from back pain. Lumbar 
spinal fusion surgery may be considered medically necessary and covered for the indications listed 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 the spinal fusion. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there has not been three months of 
non-operative therapy, there is no surgical emergency and no severe stenosis or neurologic deficit. 
 
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 spinal fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the spinal fusion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360, 88341 and 88342 billed for date of 
service February 11, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360, 88341 and 88342. You say that these services were 
reported correctly and should be paid. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360, 88341 and 
88342. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360, 
88341 and 88342. Based on this information, we decided that Medicare rules for coverage of procedure code 
88360, 88341 and 88342 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88360, 88341 and 88342 billed for date of service February 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99285 billed for August 1, 2022. 
 
You asked the Plan to pay for CPT 99285. 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 CPT 99285. Our reviewer says that the use of code 99285 is not supported by the records provided. Our reviewer found that the medical records do not support medical 
decision making of high complexity. For the use of CPT 99285, all three criteria need to be met. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for CPT code 99285 billed for August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (99442) provided on March 9, 2022. 
 
You asked the Plan to pay for telehealth services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is inclusive to another code billed. 
 
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 99442 is Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian, not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, records show there was 
another evaluation and management service provided within the last 7 days, billed using code 99214. Based on 
this information, we decided that Medicare rules for coverage of telehealth services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services (99442) provided on March 9, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, and S8301 billed for date of 
service August 3, 2022. 
 
You asked the Plan to pay for procedure codes A9279, S1015, and S8301. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the billed codes are 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 codes A9279, S1015, and S8301 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes A9279, S1015, and S8301 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A9279, S1015, and 
S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A9279, 
S1015, and S8301 billed for date of service August 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport (A0428, A0425) provided on April 18, 2022. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that it 
was medically necessary to transport this patient the doctor's appointment as the patient is bed-confined and had a suprapubic catheter that was malfunctioning. The Plan denied your request. The Plan says a physicians 
office is not a covered destination for non-emergency situations. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stabilink MIS interlaminar spinal fixation system coded 
as 22612 and 22867. 
 
You asked the Plan to pre-approve the surgical procedure. You say that please review and approve this 
procedure for the enrollee. The Plan denied your request. The Plan says Interspinous process fusion devices are 
not proven and medically necessary when used as stand-alone lumbar vertebral fusion procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve Stabilink MIS interlaminar spinal fixation system coded as 22612 and 22867.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shank foot system with vertical loading pylon (L5987) 
and an axial rotation unit (L5986). 
 
You asked the Plan to pre-approve a shank foot system with vertical loading pylon and an axial rotation unit. 
You say that these items are medically necessary. The Plan denied your request. The Plan says your needs can 
be met with lower level items. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities. 
 
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 shank foot system with vertical 
loading pylon and an axial rotation unit. Our reviewer says that the requested items are not medically 
necessary. Our physician reviewer found the documentation doesn't support that you are a K3 level ambulator 
or that you require the requested upgraded components. 
 
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 shank foot system with vertical loading pylon and an axial rotation unit have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a shank foot system with 
vertical loading pylon (L5987) and an axial rotation unit (L5986).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested use of this drug is not approved by the FDA for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the 
requested drug, Retacrit, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. Therefore, the reviewer found that the requested drug is not medically 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered for the indications 
established in the applicable LCD. 
 
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. Our reviewer says 
that a power wheelchair is not medically reasonable and necessary in this case. Our physician reviewer found 
that the requesting provider has provided insufficient information in support of the request. There is no 
description of gait beyond abnormal or description of endurance or function. There is no evidence the device 
can be used in the home. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 1 power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinalysis (81001) provided on April 7, 2022. 
 
You asked the Plan to pay for urinalysis. You say that this service was necessary and was supported as billed. 
The Plan denied your request. The Plan says the payment for this service is included in the payment for the 
drug testing services (G0480, 80307) provided on the same date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of urinalysis have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for urinalysis (81001) provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or equal (L5981) and all lower extremity prostheses, multiaxial rotation unit (L5986).
You asked the Plan to pre-approve these items. You say that you do more than simple walking. The Plan denied your request. The Plan says that the request for a K3 foot exceeds your need and does not meet the Medicare criteria of reasonable and necessary.
Our Medical director looked at the case file and the reopen request. At issue is coverage for all lower extremity prostheses, flex-walk system or equal (L5981) and all lower extremity prostheses, multiaxial rotation unit (L5986). Our Medical Director states the clinical documentation does not support that you had the ability/potential for ambulation with variable cadence, typical of community ambulatory who had the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. Our physician reviewer found that your condition does not meet criteria for coverage of these items. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or equal (L5981) and all lower extremity prostheses, multiaxial rotation unit (L5986).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the avulsion of nail plate, initial nail, (11730) and avulsion of 
each additional nail plate (11732) provided on June 4, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that the services provided are not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the avulsion of nail plate, initial nail, (11730) and avulsion of 
each additional nail plate (11732) provided on June 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computerized tomography angiography of 
the head provided on September 5, 2022. 
 
You asked the Plan to waive the copayment for computerized tomography angiography of the head. You say 
that you are disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $325 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $224.22 which is less than the $325 copayment for computerized tomography 
angiography of the head. This item/service falls within the outpatient diagnostic tests and therapeutic services 
and supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for computerized tomography 
angiography of the head provided on September 5, 2022.