Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reverse the recoupment of the 30 units of code J9145-JW reported 
for the amount of drug discarded on October 28, 2021. 
 
You asked the Plan to reverse the recoupment of the 30 units for discarded drug. You say that it was confirmed 
by a coder that this amount of drug was discarded and billed properly. The Plan denied your request. The Plan 
says Medicare requires providers to minimize wastage of drugs by using the proper dosage of vials to reach the 
required dosage given to the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should minimize drug wastage by 
selecting the best vial size available to reach the required dose.  
 We looked at the file and Medicare rules. According to the Drug HCPCS-NDC crosswalk, there are two 
available packages of the drug at issue, one which is 100mg, and another that is 400mg. The total dosage 
provided was 1600mg. The records show that three 100mg vials and four 400mg vials were opened. The entire 
amount of the three 100mg vials and three 400mg vials were given to the enrollee, and 300mg of drug was 
discarded. However, using the full amount of the four 400mg vials that were opened would have provided the 
entire dose without wasting any of the drug. There is no reason noted in the records nor the appeal letter to 
justify why three 100mg vials were used while discarding the same amount from the fourth 400mg vial.  
 
Medicare does not pay for the amount of drug that is discarded unnecessarily. Based on this information, we 
decided that Medicare rules for coverage of the 30 units for discarded drug have not been met. Therefore, we 
decided that the Plan does not have to reverse the recoupment of the 30 units of code J9145-JW reported for the 
amount of drug discarded on October 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care. 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued inpatient 
mental health care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 this service.  Our reviewer says that continued inpatient mental health care is not medically necessary. Based upon the 
review of the records provided, it was not expected that this enrollee would improve in a reasonable period of 
time for the date in question as she did not have suicidal or homicidal ideation, auditory or visual  
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the date in question as she did not have dangerousness to self or 
others and was compliant with her treatment. The health plans denial of continued inpatient psychiatric 
services is appropriate. It did not appear that active treatment was taking place beyond the date in question. It 
did not appear that the services were reasonably expected to improve the enrollees condition or were for the 
purpose of a diagnosis beyond the date in question. Based upon the review of the records provided, the enrollee 
does not meet criteria for coverage of continued inpatient mental health care beyond October 13, 2022.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services rendered on March 14, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were not performed by a physician, PA, 
or NP/CNS or under the direct supervision of one. Therefore, we decided that the Plan does not have to pay for 
the acupuncture services rendered on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a bilevel positive airway pressure (BiPAP) machine with Average volume-
assured pressure support (AVAPS) capability. The plan has indicated coverage for such a device is available 
upon request. The elements of the coverage criteria are not satisfied. 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance. 
 
You asked the Plan to pre-approve ultrasonic guidance. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 ultrasonic guidance. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found certainly using ultrasound on a daily basis is not unreasonable, but to bill for daily 
simple simulations and/or image-guided radiation therapy (IGRT) for a technology for which need has not been 
established by published data or supported by consensus guidelines (many of which recommend against 
treatment with these devices in general- citations below), billing for daily simulations or IGRT would not be 
furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasonic guidance.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing on a solid tumor sample (81479) billed for date of 
service November 27, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical records. The Plan denied your request. The Plan says that the date of service for a 
clinical laboratory test or the technical component of physician pathology service must be the date the 
specimen was collected. In this case the specimens were collected on July 6 and November 4, 2021, rather than 
the billed date of service November 27, 2021. 
 
The Plan must follow Medicare rules. The rules say that laboratory services should generally be reported with 
the date of specimen collection as the date of service. However, there are three exceptions to this rule. The 
rules also 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. Specifically, the Plan has not acknowledged or addressed the exceptions to the 
rule used in their denial. The specimen in this case was a piece of solid tumor which would have likely been 
collected as part of a biopsy procedure in a hospital setting. Therefore, it is likely that an exception to the 
general rule has been met, which would mean that the date of testing is the appropriate date of service. 
Therefore, we decided that the Plan has to pay for laboratory testing on a solid tumor sample (81479) billed for 
date of service November 27, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69220 billed for date of service May 18, 
2022. 
 You asked the Plan to pay for procedure code 69220. You say that this is correctly billed for both sides and 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 69220 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 69220 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 69220 billed for date of service May 18, 2022.
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. 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors. 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 codes E2310 and E2311 describe the electronic 
components that allow the beneficiary to control two or more of the following motors from a single interface 
(e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power 
recline, power shear reduction, power leg elevation, power seat elevation, power standing. 
 
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 electronic connection between 
wheelchair controller and two or more power seating system motors. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is able to dress, groom, and transfer 
independently. He does not require a single interface to manage the power drives on his chair. 
 
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 electronic connection between wheelchair controller and two or more power 
seating system motors 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional accessories for a leg prosthesis (L5828, 
L5999). 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says these are not reimbursable. 
 
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 additional accessories. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the L5828  Ossur Mauch Knee is not medically necessary 
per https://www.ossur.com/en-us/prosthetics/knees/mauch-knee and  the Social Security Act, Section 1862 
(a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable 
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed 
body member. The patient's weight of 360 pounds exceeds the recommended weight limit of this knee (300lbs) 
as indicated on the online website for this knee. The L5999 heavy duty feature of the foot is not medically 
necessary as this code is unbundled and exceeds the patient's medical 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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional accessories for a leg prosthesis (L5828, L5999).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive lumbar decompression (MILD) 
procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is not in an approved clinical trial. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Overall, the peer-reviewed literature 
finds only modest evidence for efficacy. Further studies are needed to prove the efficacy of this treatment over 
the gold standard surgical procedures. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested minimally 
invasive lumbar decompression (MILD) procedure at bilateral L4-5, in this case, 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the minimally invasive lumbar decompression (MILD) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee has progressive multiple sclerosis 
which has progressed to the point he has limited use of hands and legs and therefore, uses an extra-large power 
chair with head array for mobility. He requires total care and currently receives a bed bath. It would require at 
least 2 people to maneuver him in the shower with sliding chair. The request is for necessary equipment/tools 
needed for caregivers to serve individuals in the home. The Plan denied your request. The Plan says the request 
for a bathtub chair is not medically necessary because it is considered a convenience item. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with a cardiothoracic Surgeon to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that only the requested provider can do the surgery 
you need due to the size of your artery. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. The requested services can be rendered by an in-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99204) with a cardiothoracic Surgeon to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 billed for date of service December 8, 
2021. 
 
You asked the Plan to pay for procedure code 76937. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76937 is 2. You billed 3 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of procedure code 76937 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 76937 billed for date of service 
December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator. 
 
You asked the Plan to pre-approve a bone growth stimulator. 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 a spinal electrical osteogenesis stimulator (E0748) 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 a bone growth stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding a failed fusion at 9 months postoperative. The spinal fusion was only at 1 level, and not a 
multilevel fusion. There was no history of a previous spinal fusion at the L3-4 level. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, you do not meet the cover criteria detailed in the LCD. 
 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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428). 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. The Plan denied your request. 
The Plan says there is no medical need for the enrollee to require an ambulance. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation. Our reviewer says that the ambulance transport is not medically reasonable and necessary for 
the enrollee. Our physician reviewer found the documentation did not support that other means of transport 
(such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) are contraindicated for this 
enrollee. Our reviewer also found that the documentation did not support that the enrollee needs the expertise, 
services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe 
transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428).