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

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), harness for upgrade to expandable controller (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
this specific power wheelchair is what is needed to make the enrollee functional within the home as well as 
meet their positioning needs. The Plan denied your request. The Plan says that it is not medically necessary to 
control the three requested power options through the joystick (drive interface). 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing their basic daily activities. The enrollee cannot perform pressure relief 
independently and requires a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. Our reviewer found the enrollee also requires power elevating leg rests for positioning. The 
complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. Our physician reviewer found that the expandable controller with harness and electronic 
connection are necessary to operate the group 3 power wheelchair base and the power tilt and recline and 
power elevating leg rests via a joystick. There are 3 power components which require operation. Our reviewer 
also found that therefore, the expandable controller (E2377) with harness (E2313) and electronic connection 
(E2311) are 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 an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), harness for upgrade to expandable controller (E2313), 
and expandable controller (E2377).  
 
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 pre-approve a vertiflex device placement surgery (22869). 
 
You asked the Plan to pre-approve a vertiflex device placement surgery. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is considered experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vertiflex device placement surgery (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99222 and 24575 provided on September 24, 2022. 
 
You asked the Plan to pay for codes 99222 and 24575. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity.  Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
The CPT Code Manual definition of code 24575 is open treatment of humeral epicondylar fracture, medial or 
lateral, includes internal fixation, when performed. 
 
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 codes 99222 and 24575. Our reviewer says 
that the documentation does not support the codes billed. Our reviewer found the enrollee presented to the 
emergency department after falling down the stairs. The enrollee was evaluated and had a right distal humerus 
fracture. CPT code 99222 is not supported. The reviewed documentation indicates that evaluation and 
management code billed requires a comprehensive history, a comprehensive examination and medical decision 
making of moderate complexity. However, the medical records submitted did not support a comprehensive 
history and a comprehensive examination. There was medical decision making of moderate complexity. CPT 
code 24575 is not supported. The submitted medical records does not include documentation to support that 
open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation was performed; 
therefore, the billed CPT code could not be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99222 and 24575 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 99222 and 24575 provided on September 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 26, 2022, to 
June 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 26, 2022, to June 
24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for procedure code 70480. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70480 is bundled into payment for code 70450. 
 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, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70480 billed for date of service August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee is unable to stand or ambulate. You 
also say that for this enrollee, not being able to walk has significantly lowered their quality of life, and has put 
them at high risk for falls and further complicated medical outcomes. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says this drug is not a covered under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on October 3, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the place of 
service is inconsistent with another claim. 
 
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 argues that the place of service is inconsistent with another claim. 
However, the Plan has not provided documentation showing the billed place of service. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
lab services provided on October 3, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the member had multiple exams done on 
this date of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4450, A6446, and A6196 billed for date of 
service May 26, 2022. 
 
You asked the Plan to pay for procedure codes A4450, A6446, and A6196. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the billed codes are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes A4450 and A6446 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes A4450 and A6446 are statutorily excluded from Medicare coverage. 
Procedure code A6196 has a Status Indicator of P on the Physician Fee Schedule. This means that payment for 
code A6196 is bundled/excluded. Based on this information, we decided that Medicare rules for coverage of 
procedure codes A4450, A6446, and A6196 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes A4450, A6446, and A6196 billed for date of service May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. 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 PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients 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 a power operated vehicle. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the record does not indicate 
why a power wheelchair is needed to manage MRADLs. There is no evidence a manual wheelchair is not 
sufficient to allow the enrollee to manage MRADLs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for urine testing (87150, 87481, 87798, 87801, 87653 and 87640) provided 
on November 16, 2022. 
 
You asked the Plan to pay for urine testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says that these services need to be reported as a single 
panel code with a single unit of service. 
 
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. Specifically, the Plan does not cite the rule used to deny these services. We were 
unable to locate this rule in an article or determination which applies to the state where these services were 
performed. The Plan has failed to properly support their denial in this case, and has provided no other reason 
for why these services should be denied. Therefore, we decided that the Plan has to pay for urine testing 
(87150, 87481, 87798, 87801, 87653 and 87640) provided on November 16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral 
or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], single vertebral segment; 
lumbar (63047). 
 
You asked the Plan to pre-approve lumbar decompression surgery. You say that you believe that the enrollee 
would benefit from decompression surgery at L4-5. The Plan denied your request. The Plan says the records do 
not support that the enrollee meets the medically necessary criteria. 
 
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 lumbar decompression surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures (including medications and injections 
around the spinal nerves) for the noted pain and radicular symptoms. The examination findings also support 
possible other causes of her pain and symptoms. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
decompression surgery at 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 lumbar decompression surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 
decompression of spinal cord, cauda equina and/or nerve root[s], single vertebral segment; lumbar (63047).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 the enrollee is medically stable and does not need PMR physician's supervision 3 
times a week in an IRF. No acute rehab nursing needs identified or documented. The enrollee does not need 
intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. Document does not support necessity for admission to an IRF and the 
complexity of the enrollee's nursing, and medical needs does not require an acute hospital inpatient rehab stay 
with an interdisciplinary approach to rehabilitative care. While the enrollee may benefit from physical therapy, 
and occupational therapy, the enrollee's rehab needs can be provided in a lower intensity and alternate setting 
such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233) provided on July 16, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99233 is subsequent hospital care requiring a detailed 
interval history, a detailed examination and medical decision making of high complexity. 
 
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 physician services. Our reviewer says that the records do 
not support the code billed. Our reviewer found the records provided do not support medical decision making 
of high complexity. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99233) provided on July 16, 2022.