Persius/hicric huggingface dataset:
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 you are at a high risk for falling and need intensive 
therapies to help you regain your strength. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and you can get the services you need in other settings. 
 
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 that you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You can receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that you disagree with the denial. 
The Plan denied your request. The Plan says experimental and investigational procedures are not covered by 
Medicare. 
 
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 MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro orthosis is not known to be effective, based on scientific 
evidence, professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for this enrollee's condition or in widespread use for this enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's functional 
level does not require treatment by multiple therapies including physical therapy or occupational therapy in an 
intensive rehabilitation program in an IRF. The documentation does not support that the enrollee can fully 
tolerate an intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle group 1 standard (motorized 
scooter) (K0800, K0108). 
 
You asked the Plan to pre-approve a motorized scooter. You say that this is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a power operated vehicle can be covered if 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 motorized scooter. Our reviewer says 
that the criteria have not been met for coverage. Our physician reviewer found you have a mobility deficit, but 
the documentation does not support that it significantly impairs mobility-related activities of daily living 
(MRADLs) in the home and is unable to be alleviated by a standard wheelchair or walker. The documentation 
does not support that the requested scooter will significantly improve MRADL participation in the home. The 
documentation does not reveal a home evaluation indicating that you have adequate space to safely maneuver 
the scooter in the home. 
 
   
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 motorized scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power operated vehicle group 1 standard (motorized scooter) (K0800, K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22830 and 22845 provided on June 29, 
2022. 
 
You asked the Plan to pay for procedure codes 22830 and 22845. You say that the medical records support the 
billing of procedure codes 22830 and 22845. The Plan denied your request. The Plan says the medical records 
do not support the billing of procedure codes 22830 and 22845. 
 
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 22830 is a column II code to column I code 63087; however, 22830 
was billed with a modifier.  
 
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 procedure codes 22830 and 22845. Our reviewer says that 
the medical records do not support the billing of procedure codes 22830 and 22845. Our reviewer found the 
operative report does not support spinal fusion exploration as a separate distinct service as the vertebral 
corpectomy performed in same anatomical area and during same session.  Therefore, procedure code 22830 
cannot be verified as billed.  
 
Additionally, the operative report does not describe Anterior instrumentation for 2 to 3 vertebral segments. The 
procedure report documents "A 2-inch incision was made 2 inches anterior superior iliac spine obliquely...An 
osteotomy was used to perform an osteotomy of the L4 vertebral body removing more than half the body. Disc 
material was removed, and the interbody cage removed".  2-3 vertebral segments cannot be verified in the 
records to support the billing of code 22845. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 22830 and 22845 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 22830 and 22845 provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on August 29, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that the requested testing is medically necessary for 
the enrollee due to it being well established and affirmed by Medicare. The Plan denied your request. The Plan 
says Cxbladder tests are considered experimental/ investigational. The requested test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for codes 
0012M and 0013M for CxBladder. 
 
 
 We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that 
the Plan does not have to pay for CxBladder testing (0012M) provided on August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36573 billed for date of service September 9, 
2022. 
 You asked the Plan to pay for procedure code 36573. The Plan denied your request. The Plan says payment for 
code 36573 is bundled into payment for code 36569. 
 
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 36573 
is a column II code to column I code 36569. 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 36573 billed for date of service September 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on October 
19, 2022. 
 
You asked the Plan to pay for GeneSight Psychotropic testing. You say that this test was medically necessary 
and reasonable. The Plan denied your request. The Plan says the criteria for coverage of pharmacogenomics 
testing are not met in this case. 
 
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 pay for GeneSight Psychotropic testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is no documentation in the clinical record that the provider has 
already considered non-genetic factors to make a preliminary drug selection. It appears that testing was 
performed merely on the basis of the enrollees diagnosis of major depressive disorder. The GeneSight Order 
Medical Necessity Documentation for GeneSight Psychotropic dated October 19, 2022, listed the enrollees 
failed medications, which included Wellbutrin (bupropion) and Cymbalta (duloxetine). Medications listed for 
consideration for augmentation or starting/switching to included Zoloft (sertraline) and Effexor (venlafaxine). 
Though the order stated that the enrollee had failed treatment with several medications and that several 
medications were being considered for augmentation or starting/switching to, there is no documentation of such 
provided in the medical records. The review has determined that the criteria for coverage of pharmacogenomics 
testing have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GeneSight Psychotropic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 response testing (81479) provided on 
October 4, 2022. 
 
You asked the Plan to pay for the testing. You say that this test was medically reasonable and necessary. The 
Plan denied your request. The Plan says this test was not medically necessary as there is no evidence the 
enrollee has had Guardant360 CDx testing previously. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the available documentation in the case file is not sufficient to support that Guardant360 Response 
testing was medically reasonable and necessary for the enrollee in this case.  
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 pay for the Guardant360 response testing (81479) provided on October 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99284) 
rendered on July 6, 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 the code billed is 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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
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 presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function." 
 
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 not supported by the medical records. Our reviewer found that the review indicates that the 
records did not support a detailed history, and medical decision making of moderate 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (procedure code 99284) rendered on July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 21, 2022, 
and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of A41.9. 
 
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 secondary diagnosis code A41.9-sepsis unspecified 
organism. 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 documentation does not support the primary diagnosis of 
A41.9, Sepsis. Our physician reviewer found the documentation does not consistently and completely support 
the assigned secondary diagnosis code.  
 
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 on February 21, 2022, and billed with diagnosis code A41.9.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT scans. 
 
You asked the Plan to pre-approve the CT scans. You say that the enrollee would like reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says the CT scans are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scans. Our reviewer says that 
the requested CT scans are not medically necessary. Our physician reviewer found that the enrollee has 
nighttime spasms and does not have the presence of red flags signs or symptoms. The enrollee does not have 
any abnormal findings, or the medical necessity as defined by Medicare rules of the requested service. 
 
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 CT scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT scan of the thoracic spine, CT scan of the cervical spine, CT scan of the lumbar spine 
and Ct scan of the bead or brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided October 3, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. 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 (E0675) and segmental pneumatic appliances (E0673) provided 
October 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service July 15, 
2022, to July 20, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service July 15, 2022, to July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser treatment for inflammatory skin disease (psoriasis) 
(code 96920). 
 
You asked the Plan to pre-approve laser treatment for inflammatory skin disease (psoriasis) (code 96920). You 
say that the enrollee has nail dystrophy and needs laser treatment. The Plan denied your request. The Plan says 
laser treatment for inflammatory skin disease (a treatment of the skin with the use of light) is not covered under 
your current Plan for the treatment of nail dystrophy. 
 
The Plan must follow Medicare rules.  
 
 We looked at the file and Medicare rules. The file shows that the enrollee does not have a diagnosis of psoriasis 
and Medicare does not cover laser treatment for nail dystrophy. Therefore, we decided that the Plan does not 
have to pre-approve laser treatment for inflammatory skin disease (psoriasis) (code 96920).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 18, 2022.