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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe pulmonary 
hypertension, COPD, and OSA on CPAP. The enrollee was recently hospitalized for adjustment of vasodilator, 
and ABG showed mild CO2 retention. There are no pulmonary function tests to assess the severity of the 
COPD, and records note that the enrollee is not currently using inhalers, so it appears unlikely that COPD is 
contributing substantially to the CO2 retention. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. The enrollee may benefit from BiPAP during sleep as an outpatient. There is no 
documentation that this has been tried and failed. Medicare does not cover a home ventilator when used as 
BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99072, A4556, A4557, A4649, S1015, 
S8301, and A9279 billed for date of service February 7, 2022. 
 
You asked the Plan to pay for procedure codes 99072, A4556, A4557, A4649, S1015, S8301, and A9279. You 
say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan 
says procedure codes 99072, A4556, A4557, A4649, S1015, S8301, and A9279 are not separately payable. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable.  
 
We find that codes A4556, A4557, and A4649 have a status code of "P" under the Medicare Physicians Fee 
Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as 
payment is bundled into the payment for the services to which these codes are incident to.  
 
We find that procedure codes S1015, S8301, and A9279 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes S1015, S8301, and A9279 are not valid for Medicare purposes. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99072, A4556, 
A4557, A4649, S1015, S8301, and A9279 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99072, A4556, A4557, A4649, S1015, S8301, and A9279 billed for date of 
service February 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 1, 
2022, through February 3, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the acute inpatient hospital 
care provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with acute on chronic low back 
pain and difficulty walking. He denied a fall. The physical examination was unremarkable except for 
tenderness of the paraspinal muscles. He was treated with intravenous morphine, Tylenol, and hydromorphone 
and was admitted with plans for a Medrol Dosepak and outpatient physical therapy. The enrollee was stable 
and did not require an invasive procedure or treatment and was not expected to require hospital services that 
would likely cross 2 midnights based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from February 1, 2022, through February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an endoskeletal, knee-shin system, stance flexion feature (L5845), an 
endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), an endoskeletal knee-shin 
system, microprocessor control feature (L5856), an all lower extremity prosthesis, shank foot system with 
vertical loading pylon (L5987), an endoskeletal system, above knee or hip disarticulation, knee extension assist 
(L5850), an endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock (L5925) 
and an all lower extremity prostheses, multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee needs a prosthetic leg to walk and 
meets medical guidelines based on the LCD for lower limb prosthetics. The Plan denied your request. The Plan 
says the request for a K3 knee and foot do not meet Medicare criteria as reasonable and 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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested prosthetics exceed the enrollee's medical needs and are not medically necessary. 
The documentation notes the enrollee was approved for a power wheelchair in Feb 2022 prior to his amputation 
revision. Furthermore, the documentation does not support why the enrollee required a microprocessor foot 
over a mechanical foot or that the enrollee is a K3 level ambulator. Documentation indicates the enrollee feels 
tired much of the time, has back pain with activity, and has a power wheelchair. The documentation does not 
support the medical necessity of the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoskeletal knee-shin system, single axis, fluid swing and stance phase control 
(L5828), an endoskeletal, knee-shin system, stance flexion feature (L5845), an endoskeletal knee-shin system, 
fluid stance extension, dampening feature (L5848), an endoskeletal knee-shin system, microprocessor control 
feature (L5856), an all lower extremity prosthesis, shank foot system with vertical loading pylon (L5987), an 
endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), an endoskeletal system, 
above knee, knee disarticulation or hip disarticulation, manual lock (L5925) and an all lower extremity 
prostheses, multi-axial rotation unit (L5986).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood collection (36415) and travel allowance for laboratory 
specimen collection (P9603) billed for date of service September 19, 2021. 
 
You asked the Plan to pay for blood collection and travel allowance for laboratory specimen collection. You 
say that the enrollee was no longer participating in hospice on the date of service at issue. The Plan denied your 
request. The Plan says the hospice benefit and not the Plan is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for blood collection 
(36415) and travel allowance for laboratory specimen collection (P9603) billed for date of service September 
19, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 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 a group 3 power wheelchair with power options. 
 
You asked the Plan to pre-approve the wheelchair and power options. The Plan denied your request. The Plan 
says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with power options is 
covered for the indications established in the applicable LCD. 
 
 
 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 wheelchair and power options. Our 
reviewer says that the requested group 3 power wheelchair with power options is not medically reasonable and 
necessary. Our physician reviewer found that the enrollee has a neurologic disorder with functional deficits. 
The documentation does not indicate that the enrollee requires intermittent catheterization of the bladder or any 
spasticity that would necessitate power recline. Although criteria for a power wheelchair (PWC) are met, the 
criteria for the requested PWC with multiple power options, including power recline, are not 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 the wheelchair and power options have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair with power options.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for sacroiliac (SI) joint 
(64451 x 2). 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested SI injections 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 the injections. Our reviewer says that 
the requested injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiofrequency for sacroiliac joint pain is considered experimental and investigational. 
Therefore, the reviewer found that the requested injections are 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) for sacroiliac (SI) joint (64451 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that these services were necessary. The Plan 
denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service March 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 15, 2020, to 
March 24, 2020, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported appropriately and are supported as billed. The Plan denied your request. The Plan says 
they have agreed that diagnosis code N39.0 is appropriate in this case; however, other diagnoses reported on 
this claim are not supported, and therefore the submitted DRG is not appropriate. 
 
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 toxic encephalopathy (G92) and hypothermia, 
initial encounter (T68.XXXA). 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 these diagnoses are not supported in the 
medical records. Our physician reviewer found that the enrollee presented to the emergency department on 
March 15, 2020, with chills and dyspnea. On presentation her temperature was 33.8 degrees Celsius. 
Evaluation revealed a white blood cell count of 5.7, and she was evaluated by Infectious Disease. There was no 
evidence of a urinary tract infection (UTI). In this case there was no clinical or laboratory evidence of 
metabolic encephalopathy. There was no documentation of any mental status changes during the 
hospitalization. In addition, primary hypothermia is due to environmental exposure, with no underlying 
medical condition causing disruption of temperature regulation. In this case the enrollee had a diagnosis of 
hypothermia. There was no history of any environmental exposure; therefore, the submitted code is not 
supported. The review has determined that the documentation did not support toxic encephalopathy (G92) and 
hypothermia, initial encounter (T68.XXXA).  
 
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 March 15, 2020, to March 24, 2020, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 25337 and 29846 for services provided on June 24, 
2022. 
 
You asked the Plan to pay for codes 25337 and 29846. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 25337 is reconstruction for stabilization of unstable distal 
ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, 
or tenodesis) with or without open reduction of distal radioulnar joint. 
The CPT Code Manual definition of code 29846 is arthroscopy, wrist, surgical; excision and/or repair of 
triangular fibrocartilage and/or joint debridement.  
We find that CPT codes 25337 and 29846 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a reconstruction for stabilization of unstable distal ulna or distal 
radioulnar joint, secondary by soft tissue stabilization (tendon transfer, tendon graft or weave, or tenodesis) 
with or without 
open reduction of distal radioulnar joint; therefore, code 25337 cannot be verified. 
The operative report did not include documentation of a reconstruction for stabilization of unstable distal ulna 
or distal radioulnar joint, secondary by soft tissue stabilization (tendon transfer, tendon graft or weave, or 
tenodesis) with or without open reduction of distal radioulnar joint; therefore, code 29846 cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of codes 25337 and 29846 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 25337 and 29846 for services 
provided on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
in bones of spine in lower back, first two bones (Intracept) procedure (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that you have had ablation, steroid injections 
in the past. You say that they do not last long enough. You also say that your physical medicine and 
rehabilitation specialist has recommended this procedure because it targets a specific area of pain. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental. Therefore, the reviewer found 
that the Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve in bones of spine in lower back, 
first two bones (Intracept) procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the face down recovery chair purchased on August 11, 
2022. 
 
You asked the Plan to reimburse for the face down recovery chair. You say that the chair is medically 
necessary. You state you are requesting reimbursement of services rendered. The Plan denied your request. The 
Plan says these types of devices are considered "precautionary devices" and also can be used for purposes other 
than the treatment of an illness or injury. The Plan must follow Medicare rules. The rules say that for 
equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not 
serve a purpose that is primarily medical in nature. This item is available to the general public and would be 
helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to 
reimburse for the face down recovery chair purchased on August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on November 30, 2021. 
 
You asked the Plan to pay for the testing services. You say that medical records were provided. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the panel testing provided on November 30, 2021.