Persius/hicric huggingface dataset:
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 are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the SNF services requested do not meet the 
requirements for approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, the 
enrollee does not require skilled therapy services on a daily basis. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. The enrollee does 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 8, 
2022. 
  You asked the Plan to pay for procedure code 99100. You say that you do not have the financial means to pay 
this. The Plan denied your request. The Plan says procedure code 00902 has already been paid and procedure 
code 99100 is considered bundled and not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 22, 2022, billed with 
codes 81225, 81306, 81306, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81355, 81355, 81401, 
0031U, 0032U, 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records have been attached to 
this appeal. Please have a look at the attachment and reconsider the charges which were previously denied. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Also, there is insufficient information in the records to determine if Medicare rules for coverage of 
the genetic testing have been met. Additional records were needed and requested from the provider. The 
records show that the Plan made multiple attempts to obtain the needed records from the provider without 
success. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 22, 2022, billed with codes 81225, 81306, 81306, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 
81291, 81355, 81355, 81401, 0031U, 0032U, 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for November 18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99223 was billed with POS code 
21 for inpatient; however, the enrollee was under outpatient observation status for the date of service at issue. Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for November 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies billed for date of service September 30, 
2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that sometimes your organization ships the items 
early in order to ensure that the patient receives them on time. The Plan denied your request. The Plan says the 
proof of delivery submitted does not match the date of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the date that the beneficiary receives the item 
should be the date of service on the claim. If the supplier uses a delivery/shipping service, the supplier may also 
use the shipping date as the date of service on the claim. 
 
In this case, the records show that the packing slip wasn't even created until October 3, 2022, and the item in 
dispute was delivered on October 7, 2022.  You did not use either of these dates as the date of service on the 
claim as is required.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the diabetic supplies billed for date of service September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (codes A4557 and A4595) 
billed for date of service October 4, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that this claim was billed 
appropriately, and the patient's physician recommended lifetime use of these items. The Plan denied your 
request. The Plan says the ordering provider is not appropriate for these items. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following provider types can prescribe 
durable medical equipment: physicians, physician assistants, nurse practitioners, or clinical nurse specialists. Medicare defines physicians as the following: doctors of medicine or osteopathy, doctors of dental surgery or 
dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors. 
 
In this case, the items in question were ordered by a physical therapist with a Doctor of Physical Therapy 
degree.  Medicare does not consider this specialty to be a 'physician' for purposes of ordering durable medical 
equipment. Therefore, this provider type is ineligible to order these items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for electrical stimulator supplies (codes A4557 and A4595) billed for date of service October 4, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro power-assisted upper extremity brace. 
 
You asked the Plan to pre-approve the MyoPro powered brace. You say that this device will be able to assist 
the enrollee in activities as standard therapies have not been helpful. The Plan denied your request. The Plan 
says this is considered experimental at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro powered brace. 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. There is insufficient evidence in the literature 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 the MyoPro powered brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro power-assisted upper extremity brace.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for catheters billed with code A4338 for date of service November 30, 
2022. 
 
You asked the Plan to pay for the catheters. You say that the patient uses these Foley catheters for tube 
feedings via an ostomy.  You claim that the Plan authorized the use of these catheters for this purpose and that 
the number of catheters provided is medically necessary and documented. The Plan denied your request. The 
Plan says that the MUE value of code A4338 is 0, so no units of this item are covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There are several problems with the case file that the Plan submitted to us and 
with the Plan's denial rationale.  Specifically, the Plan's sole rationale for denial is that the MUE value for this 
code is 0, so no units of this code are payable.  This is not true.  It appears that the Plan incorrectly referenced 
the MUE table for Practitioner Services and not the one for Durable Medical Equipment (DME).  The DME 
MUE table does NOT list code A4338 as having a MUE value of 0, but rather 3 units.  Further, this code has a 
MAI indicator of 3, meaning that there must be documentation in the medical records as to why excess units 
are required. 
 
First, there is clear documentation in the medical record as to why additional units are required.  The medical 
records explicitly state that "the patient requires three Foley catheters per day for his tube feedings via his ostomy."  The Plan has provided no assertion that this is not true.  The Plan has provided no argument that 
these additional units are not medically necessary.   
 
Second, in your appeal request, you stated that the Plan prior authorized the number of units being billed.  In its 
case file submission to us, the Plan has failed to address this at all.  The Plan has failed to provide any 
documentation regarding the extent of the authorization that was or was not present for these catheters.  The 
burden is on the Plan to show why its denial was appropriate.  By relying on an incorrect MUE table, by failing 
to address the explicit statement of medical necessity in the medical records, and by failing to document 
anything related to this authorization, we find that the Plan has not met its burden. Therefore, we decided that 
the Plan has to pay for catheters billed with code A4338 for date of service November 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the enrollee has been having headaches greater than 15 
a month, with greater than 4 migraines lasting over 4 hours. You also say that the enrollee's headaches 
consistent of symptoms of pulsating pain, retro-orbital pain, eye watering, and has been extremely depressed 
due to pain. The Plan denied your request. The Plan says this request cannot be approved at this time because 
the notes do not indicate what type of migraine the enrollee is having, what their specific symptoms are from 
their headaches, or how many migraines per month. 
 
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 Botox. Our reviewer says that Botox is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of headache. The record does not indicate that the enrollee has chronic migraine 
headaches at least 15 days per month with headache lasting 4 hours a day or longer. Our reviewer found that 
the record also indicates that the enrollee has not had any improvement from a previous treatment with the 
requested drug. The FDA 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. Our physician reviewer also found that the elements of the coverage criteria are not 
satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox (J0585).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Invitae Hyperparathyroidism panel (81479). 
 
You asked the Plan to pre-approve the Invitae Hyperparathyroidism panel. You say that this test is medically 
necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of the Invitae Hyperparathyroidism panel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Invitae Hyperparathyroidism panel (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression devices (E0650, E0666, 
E0673, 97760). 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the items are medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for the prevention of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression 
devices (E0650, E0666, E0673, 97760).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9379 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code S9379. You say that the services at issue have been billed 
correctly. 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 S9379 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9379 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9379 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9379 billed for date of service November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve D2750 for tooth #9 and #10. We decided that the Plan does not 
have to pre-approve D2750 for tooth #21.  
 You asked the Plan to pre-approve a crown restoration (D2750) for tooth #10, #21, and #9. You say that you 
need this dental work. The Plan says that the medical criteria for D2750 have not been met. 
 
We decided that the Plan has to pre-approveD2750 for tooth #9 and #10.  
 
Our doctor found that D2750 is medically necessary for tooth #9 and #10. D2750 is not medically necessary for 
tooth #21. Therefore, we decided that the Plan has to pre-approve D2750 for tooth #9 and #10.  
 
We also decided that the Plan does not have to pre-approve D2750 for tooth #21. 
 
Our doctor found that D2750 is not medically necessary. Therefore, we decided that the Plan does not have to 
pre-approve D2750 for tooth #21. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH offers better service. The Plan 
denied your request. The Plan says the denial of LTACH service is correct. 
 
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 you do not require services at the LTACH that are not available at the health care 
setting being offered by the Plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 you are requesting reconsideration 
stating the enrollee currently meets acute LTACH admission criteria. The Plan denied your request. The Plan 
says the LTACH services requested 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you had these benefits in 2022 with the same 
illness. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).