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

 
We decided that the Plan does not have to pre-approve clinical research study services. 
 
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 services related to clinical trials are covered by Original Medicare. 
 The Plan must follow Medicare rules. the rules say that Original Medicare is responsible for the costs 
associated with clinical trials. 
 
We looked at the file and Medicare rules. The file shows that the services at issue are part of a clinical trial. 
The Plan does not cover services related to clinical trials. Therefore, we decided that the Plan does not have to 
pre-approve clinical research study services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cataract surgery, Eye Lens Implant; Astigmatism (V2787), 
provided on June 23, 2022. 
 
You asked the Plan to pay for Astigmatism Correcting Intraocular Lens. You say that the service was medically 
necessary. The Plan denied your request. The Plan says Astigmatism Correcting Intraocular Lens are not 
covered by Medicare the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for a cataract surgery, 
Eye Lens Implant; Astigmatism (V2787), provided on June 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a cardiac contractility modulation 
system in the form of the Optimizer Smart device (CCM). 
 
You asked the Plan to pre-approve implantation of a cardiac contractility modulation system in the form of the 
Optimizer Smart device (CCM). You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested services are 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 implantation of a cardiac contractility 
modulation system in the form of the Optimizer Smart device (CCM). Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has left ventricular dysfunction with continued symptoms, despite medical treatment, 
thought to reflect congestive heart failure. Several randomized clinical trials of CCM versus control have also 
been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing 
meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as 
well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically 
rigorous studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a cardiac contractility modulation system in the form of the 
Optimizer Smart device (CCM) have not been met. Therefore, we decided that the Plan does not have to pre-
approve implantation of a cardiac contractility modulation system in the form of the Optimizer Smart device 
(CCM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88112, 88312, 88305, 88361) billed for 
date of service April 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue have been reported and 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of laboratory services have been met. The 
case record does not contain the results of the laboratory services at issue or documentation to support the 
medical necessity of the services. Therefore, we decided that the Plan does not have to pay for laboratory 
services (88112, 88312, 88305, 88361) billed for date of service April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services, provided on June 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the service should be covered. The Plan 
denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until September 12, 2022.. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services, provided on June 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical nasopharyngoscopy procedure (69705, 
69706). 
 
You asked the Plan to pre-approve a surgical nasopharyngoscopy. You say that the requested services are a 
medical necessity for you. The Plan denied your request. The Plan says the request 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 a surgical nasopharyngoscopy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is insufficient literature to support the safety and efficacy, as defined 
by Medicare rules, of the requested service for your clinical condition. 
 
 
  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 surgical nasopharyngoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a surgical nasopharyngoscopy procedure (69705, 69706).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electroencephalogram (EEG) with extended 
monitoring (95812) and an electroencephalogram (EEG) including recording awake and asleep (95819). 
 
You asked the Plan to pre-approve the EEGs. You say that this test is needed in order to rule out possible 
seizure activity and diagnosis patient correctly. You also say that the plan of treatment for this enrollee cannot 
be established until further testing is completed. The Plan denied your request. The Plan says this request 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 the EEGs. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is said to have orthostatic hypotension and an episode of syncope. There was no 
discussion in the records provided that the enrollee was suspected of having seizures or a seizure disorder. Our 
reviewer found that generally, an EEG is only done for the evaluation of seizures/suspected seizures. There was 
nothing in the documentation provided suggesting the presence of seizures. Our physician reviewer also found 
that it cannot be determined that the requested service would be reasonable and necessary for the enrollee 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 the EEGs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electroencephalogram (EEG) with extended monitoring (95812) and an 
electroencephalogram (EEG) including recording awake and asleep (95819).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to show the 
medical necessity of these services. 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 September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services, provided on July 27, 2022. 
 
You asked the Plan to pay for the physician services. You say that the service should be covered. The Plan 
denied your request. The Plan says you were enrolled in hospice during this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the physician services, provided on July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro orthotic device. 
 
You asked the Plan to pre-approve MyoPro orthotic device. 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. 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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 MyoPro orthotic device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MyoPro orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve the MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item 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 the MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 
patient's condition or in widespread use for this patient'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 
patient. 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 the MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152 and 
99153) provided to the enrollee on April 13, 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 Current Procedural Terminology (CPT) codes 99152 and 99153 remain 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 the denied codes is: 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
CPT 99153: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service) 
 
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 documentation submitted did 
not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status; therefore, the billed service cannot be verified. Of note, an independent 
trained observer is someone other than the physician performing the services. Additionally, CPT code 99153 
has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the 2022 National Physician 
Fee Schedule Relative Value File April Release. CPT code 99153 may not be paid if furnished to hospital 
inpatients or patients in a hospital outpatient department. 
 
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 moderate sedation services (procedure code 99152 and 99153) provided to the enrollee on April 
13, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for pathology services (88307-26, 88304-26) provided on July 14, 2022. 
 
You asked the Plan to pay for pathology services. You say that these services were necessary, referred by the 
enrollee's treating physician, and were reported correctly. The Plan denied your request. The Plan says that the 
payment for these charges is included in the facility rate. 
 
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 has not clearly explained their reason for denial and has 
not supplied a relevant citation and supporting evidence. In addition, the original claim for these services was 
not included in the case file. The Plan's denial is not substantiated in this case. Therefore, we decided that the 
Plan has to pay for pathology services (88307-26, 88304-26) provided on July 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for date of service 
October 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation shows medical necessity. The 
Plan denied your request. The Plan says the documentation does not support the charges. 
 
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.  
 
We looked at the file and the rules. The Plan confirmed with the enrollee that the billed supplies were not 
received. The medical records do not show that the durable medical equipment was part of the enrollees 
treatment plan.  The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the durable 
medical equipment billed for date of service October 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do not want to go to a nursing facility because 
you need more therapy. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the patient lift provided on August 31, 2022. 
 
You asked the Plan to pay for the patient lift. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item rendered is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that patient lifts are only covered for certain indications. 
 
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 patient lift. Our reviewer says that the 
documentation does not support that Our physician reviewer found the documentation does not show 
documentation of the enrollee's function. This means the documentation does not support that if transfer 
between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the enrollee would 
be bed confined. Therefore, the enrollee did not meet criteria for the device rendered. 
 
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 patient lift have not been met. Therefore, we decided that the Plan does not 
have to pay for the patient lift provided on August 31, 2022.