Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy (procedure code 29823) provided to the 
enrollee on August 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies])." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrolle was being treated for a 
superior glenoid labrum lesion of the right shoulder. He underwent a right shoulder arthroscopy, rotator cuff 
repair, full-thickness supraspinatus tear, subacromial decompression, labral debridement, and biceps 
debridement on 8/25/22. The procedure detailed there was a superior labral tear and some mild biceps 
tendinosis. Both of these areas were debrided. The biceps anchor was stable. The full-thickness supraspinatus 
tear was visualized and debrided from the articular surface. Therefore, the records do support that CPT 29823: 
arthroscopy, shoulder, surgical, debridement, extensive 3 or more discrete structures (e.g., humeral bone, 
humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, 
labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, 
foreign body[ies]) was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical shoulder arthroscopy (procedure code 29823) provided to the enrollee on August 25, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous 24-hour, 7 day per week private duty 
nursing. 
 
You asked the Plan to pre-approve continuous 24-hour, 7 day per week private duty nursing. You say that the 
records provided support the need for the requested services. The Plan denied your request. The Plan says 
home health and skilled services greater than 35 hours a week is beyond the federal statutory limit of maximum 
number of hours that Medicare can cover. 
 
The Plan must follow Medicare rules. Medicare rules say that for home health aide services to be covered, the 
services provided by the home health aide must be part-time or intermittent. 
 
We looked at the file and Medicare rules. You are requesting coverage for full-time home health aide services which are not intermittent. Based on this information, we decided that Medicare rules for coverage of private 
duty nursing have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous 
24-hour, 7 day per week private duty nursing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee requires the requested 
wheelchair with power tilt and recline to meet her medical, functional, mobility needs, and pressure relief needs 
throughout the day in her home. The Plan denied your request. The Plan says the requested accessories cannot 
be covered. 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 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 patient's 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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee does not require a 
ventilator, or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require 
a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative 
speech device or computer through the chair's drive control), or an attendant control. The enrollee has power 
options on the wheelchair, but she does not need to control the power options through a joystick. The enrollee's 
upper extremity strength supports that she can control any power options through their own switches. 
 
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 electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty (TKA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TKA is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for left 
knee unilateral primary osteoarthritis. Detailed documentation is not evident regarding a trial and failure of 
recent, reasonable, and comprehensive less invasive conservative care measures. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested total knee replacement in this clinical 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested total knee arthroplasty (TKA) 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total knee arthroplasty (TKA).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller with harness and electronic connection. 
We decided that the Plan does not have to pre-approve a power seat elevation system.  
 
You asked the Plan to pre-approve an expandable controller (E2377) with harness (E2313) and electronic 
connection (E2311) and for a power seat elevation system (E2300) for a power wheelchair. You say that the 
requested items are a medical necessity for you. The Plan says that the request is not medically necessary. 
 
We decided that the Plan has to pre-approve an expandable controller with harness and electronic 
connection.  
 
The Plan follows Medicare rules. The rules say that an expandable controller is capable of accommodating one 
or more of the additional functions listed in the Medicare rules section of this letter. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller with harness 
and electronic connection. Our reviewer says that an expandable controller with harness and electronic 
connection is medically reasonable and necessary in this case. Our physician reviewer found that the 
complexity of your seating and positioning needs necessitates a more complex Group 3 power wheelchair base. 
The expandable controller with harness and electronic connection is necessary to operate the Group 3 power 
wheelchair base and the power tilt and recline and power elevating leg rests via a joystick.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve an expandable controller with harness and electronic 
connection.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on this 
information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 16, 
2022. You asked the Plan to pay for procedure code 99100. You say that pre-authorization was not required. The Plan 
denied your request. The Plan says 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 19, 2022, to January 24, 2022. 
 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
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 DRG 854. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that review has determined that the documentation did not support diagnosis codes A41.51 -sepsis due to 
Escherichia coli [E. coli], A41.89 - other specified sepsis, or R65.20 - severe sepsis without septic shock. The 
records do not support the original DRG 854. The revised DRG 418 is appropriate. A review of the medical 
record found no evidence of clinical symptoms or findings on physical exam consistent with a diagnosis of 
sepsis.  
 
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 
for inpatient hospital services provided to the enrollee from January 19, 2022, to January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment and implant supported crown 
(D6057, D6066) provided on September 27, 2022. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair". 
You say that the services should be covered as you disagree with the denial. The Plan denied your request. The 
Plan says the services denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment and implant supported crown (D6057, D6066) provided on September 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says medical studies have not proven that the application of the 
product(s) is helpful for treatment of the enrollee's spinal condition when the spinal surgery is being done from 
a posterior approach. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
right total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. 
The Plan says there is no documentation provided to support the expectation the enrollee will require a greater 
than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is scheduled/approved for a right total shoulder arthroplasty. 
The record does not document that the treating physician has a reasonable expectation of a length of stay 
spanning 2 or more 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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 the services are necessary for the enrollee to receive daily physician monitoring and interventions. The Plan denied your request. The Plan says the enrollee's care can be provided in the current inpatient hospital.

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 there is no evidence that the enrollee requires services that are not currently available. The enrollee can remain at the current acute care hospital until no acute services are required. The enrollee can then be transferred or discharged to a lower level of care for any ongoing long term care needs.

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PushTracker E3 (E0986). 
 
You asked the Plan to pre-approve a PushTracker E3. You say that the records provided support the necessity 
of the requested services. The Plan denied your request. The Plan says a PushTracker E3 is not primarily used 
to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a PushTracker E3 (E0986).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Signatera Bespoke ctDNA assay test. 
 
You asked the Plan to pre-approve the testing. You say that this is needed to determine the next step in care. 
The Plan denied your request. The Plan says the records show radiographic evidence of disease progression. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the use of ctDNA for Merkel cell carcinoma is not supported by the National Comprehensive Care 
Network (NCCN) guidelines. Given obvious changes on the positron emission tomography (PET) scan, it is not 
clear how this test alters the patient's management. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Signatera Bespoke ctDNA assay test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve patient lift. 
 
You asked the Plan to pre-approve patient lift. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says this item has a rental cap. 
 
The Plan must follow Medicare rules. Medicare rules say that if the purchase option is exercised, payment of 
rental fees is not to exceed a period of continuous use of 13 months and ownership of the equipment passes to 
the enrollee. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of patient lift have not been met after January 2023 as 13 months would have passed. Therefore, we 
decided that the Plan does not have to pre-approve patient lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat liner (K0108). 
 
You asked the Plan to pre-approve a seat liner. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the approved seat cushion includes all parts needed for it to work correctly. The 
requested liner is an addition to the seat cushion and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The LCD confirms that wheelchair seat and back cushion codes are 
all-inclusive. The use of code K0108 to separately bill for added components such as the requested seat liner, is 
incorrect coding. Based on this information, we decided that Medicare rules for coverage of a seat liner have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a seat liner (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery cover. 
 
You asked the Plan to pre-approve a battery cover. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery cover.