Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), 
amplified probe technique (U0003) provided March 30, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that as required by the CDC, you needed to have 
a COVID-19 test done 24 hours before you re-entered the United States. The Plan denied your request. The 
Plan says services not covered under foreign benefit. COVID-19 testing for non-diagnostic testing for 
screening purposes is not covered by Medicare. 
 
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. 
 
The test at issue in this appeal, the laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the infectious agent detection by nucleic acid (DNA or RNA); Severe Acute Respiratory Syndrome 
Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique (U0003) 
provided March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding teeth to existing partial denture (D5650) provided on 
July 7, 2022. 
 
You asked the Plan to pay for adding teeth to existing partial denture (D5650). You say that your upper partial 
denture was broken, and two missing had to be added for it to be repaired. You say that you have no means to 
pay this amount. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 adding 
teeth to existing partial denture (D5650) provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that you need this service. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy of the small bowel is 
considered medically reasonable and necessary when the conditions have been 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 a wireless capsule endoscopy. Our 
reviewer says that a wireless capsule endoscopy is not medically necessary. Our physician reviewer found your 
extensive evaluation over a two to three year period supports no evidence nor suspicion that your symptoms are 
to any significant degree of clinical likelihood related to occult Crohn's disease. Therefore, the reviewer found 
that none of the medically necessary indications provided are met for a repeat capsule endoscopy at this time. 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy provided by a participating 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT sessions are medically 
necessary. The Plan denied your request. The Plan says additional PT sessions are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
  
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet injections. 
 
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 facet blocks are 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 radiculopathy is documented in the 
submitted records but there is no documentation of a minimum of three months of failure to respond to 
noninvasive/conservative management. The criteria for coverage are not met and the services are not 
raesonable or 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 lumbar facet injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional ten physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional ten PT visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 additional ten PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills 
of a professional therapist are required to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. You should be able to transition to an independent home program at this point. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
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 additional ten PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional ten physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental 
pneumatic appliances (E0673) provided November 5, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that you have attached 
supporting documentation to this appeal which demonstrates the medical necessity of the procedures related to 
this claim. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and segmental pneumatic appliances (E0673) provided 
November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial facial prosthesis, fabrication and fitting of ocular 
conformer, and scleral cover shell provided on May 24, 2022. 
 
You asked the Plan to pay for the partial facial prosthesis, fabrication and fitting of ocular conformer, and 
scleral cover shell. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the documentation did not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid physician order for the supplies provided in this case. Review of the file 
shows that these services cannot be verified as there was no valid physician order in the case file. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the partial facial prosthesis, fabrication and fitting of ocular 
conformer, and scleral cover shell provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an eye examination (92004) provided on August 17, 2021. 
 
You asked the Plan to pay for an eye examination. You say that you want the Plan to pay for the eye 
examination. The Plan denied your request. The Plan says that the claim was processed correctly. 
 
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. The Plan did not address the appeal of the eye examination and provided no 
rationale that it was denied correctly. Therefore, we decided that the Plan has to pay for an eye examination 
(92004) provided on August 17, 2021.  
 
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 pre-approve injections. 
 
You asked the Plan to pre-approve injections. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary 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 injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD requires 80% improvement in 2 
sets of diagnostic blocks. This was not achieved and therefore, the request is deemed not medically reasonable 
or 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and related accessories and features. 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and related accessories and features. 
You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The 
Plan says rules for coverage for a Group 3 standard power wheelchair with multiple power options have not 
been met. 
 
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 Group 3 standard power wheelchair 
and related accessories and features. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee does not have high risk 
for skin breakdown, use a ventilator or require intermittent catheterization. The enrollee does not require the 
power tilt and recline system as the enrollee does not have skin issues or spasticity. 
 
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 Group 3 standard power wheelchair and related accessories and features have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power options (K0861) and related accessories and features.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77002-26-RT and 77002-26-XU-LT billed 
for date of service February 23, 2022. 
 
You asked the Plan to pay for two units of code 77002. You say that these services are supported as billed. The 
Plan denied your request. The Plan says these services were not billed in accordance with Medicare guidelines. 
 
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 77002 is fluoroscopic guidance for needle placement 
(e.g., biopsy, aspiration, injection, localization device) (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 two units of code 77002. Our reviewer says that billing two 
separate units of 77002 is not warranted per Medicare guidelines. Our reviewer found according to coding guidelines, the Medically Unlikely Edit (MUE) for code 77002 is 1. Proper billing would be to code only one 
unit of 77002 with modifier 26. There is no need to indicate which side, as this procedure is added on to code 
20605 which was indicated with modifier 50 for a bilateral service. Fluoroscopic guidance was only used once 
to insert the needle. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two units of code 77002 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 77002-26-RT and 77002-26-XU-LT billed for date of service 
February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0031U, 0032U, 0033U, 81225, 81226, 81227, 
81230, 81231, 81232) provided on May 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes 
a single procedural service, so one procedure code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple codes were billed for a single panel. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (0031U, 0032U, 0033U, 81225, 81226, 81227, 
81230, 81231, 81232) provided on May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 24, 2022, to June 
29, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the provided documentation indicates that at the time of inpatient admission, the admitting 
physician reasonably expected that the enrollee's necessary hospital care would span two midnights. Therefore, 
the reviewer found that the inpatient admission was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from June 24, 2022, to June 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid 
analysis for lymphedema assessment (L-Dex device) (93702). 
 
You asked the Plan to pre-approve BIS assessment. You say that the enrollee is at high risk for developing 
lymphedema. You also say that the use of the L-Dex device is medically necessary. The Plan denied your 
request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve BIS assessment. Our reviewer says that 
the requested BIS assessment is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested service is considered experimental or investigational. There is insufficient 
literature to establish the requested test as safe and effective. Therefore, the reviewer found that the requested 
BIS assessment is not medically reasonable or 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 BIS assessment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment 
(L-Dex device) (93702).