Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal coronary angioplasty; single 
major coronary artery or branch (92920) and percutaneous transcatheter placement of intracoronary stent(s), 
with coronary angioplasty when performed; single major coronary artery or branch (92928). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has aortic heart murmur, server 
calcific aortic valve stenosis, and right bundle branch block that the enrollee needs the catheter put in to make 
blood flow better. The Plan denied your request. The Plan says your request is not medically necessary because 
the enrollee's records show the enrollee does not have angina refractory to medical management, or objective 
evidence of ischemia. 
 
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 services. Our physician reviewer 
found at issue is the medical appropriateness and necessity for performance of cardiac catheterization and 
percutaneous coronary intervention (PCI) at this time. Non-invasive workup, including echocardiogram, would 
be appropriate and has been ordered, but not yet done. The guidelines do not support a need for PCI in this 
setting. As a result, at this time cardiac catheterization and PCI would not be considered medically appropriate 
and necessary in this enrollee's clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transluminal coronary angioplasty; single major coronary artery or branch 
(92920) and percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when 
performed; single major coronary artery or branch (92928).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 7, 2021. 
 
You asked the Plan to pay for the lab 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 the lab services provided on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement continuous airway pressure (CPAP) 
device. 
 
You asked the Plan to pre-approve a replacement CPAP device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that continued CPAP is covered when the enrollee meets 
adherence to therapy criteria which is defined as use of PAP greater than or equal to 4 hours per night on 70% 
of nights during a consecutive thirty (30) day period anytime during the first three months of initial usage. 
 
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 replacement CPAP device. Our 
reviewer says that the documentation does not support that Our physician reviewer found the enrollee has 
obstructive sleep apnea. The documentation shows that the enrollee's compliance from November 4, 2022, to 
February 1, 2023, was 14%. This does not meet minimum Medicare criteria of 70% of nights. This means the 
recent compliance reports indicate the enrollee is not using the device enough to be effective. Therefore, the 
enrollee does not meet criteria for the requested device. 
 
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 replacement CPAP device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a replacement continuous airway pressure (CPAP) device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 20, 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 July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on 
September 2, 2022, billed with code 99310. 
 
You asked the Plan to pay for the EM services as billed. You say that this was denied incorrectly as the 
services were medically necessary. The Plan denied your request. The Plan says the code billed in this case is 
not appropriate for the services rendered. 
 
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 99310 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive 
interval history; A comprehensive examination; Medical decision making of high 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. The patient may 
be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
We find that CPT code 99310 is not supported in the medical record. Specifically, this code is used for services 
provided in a nursing facility, and the enrollee was in an assisted living facility on this date of service. There is 
a more appropriate code for this situation. Based on this information, we decided that Medicare rules for 
coverage of the EM services as billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management (EM) services provided on September 2, 2022, billed with code 99310.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483). 
 
You asked the Plan to pre-approve a repeat TFESI. You say that you feel you would benefit from another 
injection. The Plan denied your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat TFESI. Our reviewer says that 
a repeat TFESI is not medically necessary. Our physician reviewer found the provided documentation does not 
support that you had 50% pain relief for three months. Therefore, the reviewer found that a repeat injection 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 a repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Vertiflex device is experimental. More research is needed to show 
safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an alignable system. We decided that the Plan does not have to 
pre-approve a protective cover.  
 
You asked the Plan to pre-approve an alignable system (L5910) and a flexible protective outer surface covering 
system (L5962).. You say that the services are necessary. The Plan says that based on the documentation 
provided, coverage criteria have not been met. 
 
 
 
 We decided that the Plan has to pre-approve an alignable system.  
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an alignable system. Our reviewer says 
that the services are medically necessary. Our physician reviewer found per the coverage criteria, both 
physician and prosthetist recommend the suction suspension system and the enrollee has complaints about 
current prosthesis. 
 
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 alignable system have been met. Therefore, we decided that the Plan has to 
pre-approve an alignable system.  
 
We also decided that the Plan does not have to pre-approve a protective cover. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a protective cover. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a protective cover is not necessary 
as the enrollee is not functioning in a harsh environment.  
 
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 protective cover have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a protective cover. 
 
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 transection or avulsion of the greater occipital nerve 
(64744). 
 
You asked the Plan to pre-approve the transection or avulsion of the greater occipital nerve. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says this service is investigational 
and is non-covered. 
 
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 transection or avulsion of the 
greater occipital nerve. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there have not been studies which show that this 
procedure is superior to standard treatments. Published studies do not demonstrate any long-term health 
outcome advantage with the use of these procedures as an alternative to standard treatments. 
 
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 transection or avulsion of the greater occipital nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a transection or avulsion of the greater 
occipital nerve (64744).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an Axio transcutaneous electrical nerve stimulation (TENS) and 
neuromuscular electrical stimulation (NMES) device (E1399, L3999, L2999, L1499). 
 
You asked the Plan to pre-approve the Axio device. You say that this device is medically necessary. The Plan 
denied your request. The Plan says that combination stimulation devices are experimental and non-covered. 
 
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 the Axio device. Our reviewer says that 
the requested item is considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has had Epidural steroid injections as well as Rhizotomy and Ablation. He takes Oxycodone and 
Fentanyl for pain. He had a TENS and NMES trial with 50% pain relief for 6 months. The requested stimulator 
is 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 the Axio device have been met. Therefore, we decided that the Plan has to pre-
approve an Axio transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation 
(NMES) device (E1399, L3999, L2999, L1499).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these services are included in the dialysis rate. The Plan 
denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing billed with code 83789 for date(s) of 
service August 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for the validity testing billed with 
code 83789 for date(s) of service August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
(E0955, E0956, E1002, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0108, K0856). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with a single power option. You say that this 
wheelchair is medically necessary. The Plan denied your request. The Plan says the type of power wheelchair 
requested exceeds the enrollee's needs. 
 
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 the group 3 power wheelchair with a 
single power option. Our reviewer says that the requested wheelchair is not medically necessary. Our physician 
reviewer found the records show that the enrollee requires a power wheelchair for mobility and accomplishing 
her daily activities. However, the clinical documentation does not show that a lower-level power wheelchair 
would not meet the enrollees needs. It is not clear why she cannot adequately perform pressure relief 
independently. Additionally, there is no clinical history of lower extremity lymphedema or spasticity that 
would require power elevating leg rests. 
 
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 group 3 power wheelchair with a single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single 
power option (E0955, E0956, E1002, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0108, 
K0856).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electrical connection to control one power feature through the 
wheelchair controller (E2310) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the electrical connector to control one power feature. You say that this 
feature is medically necessary. The Plan denied your request. The Plan says that the enrollee can operate the 
power tilt feature through the standard switched. 
 
The Plan follows Medicare rules. Medicare rules say that codes E2310 and E2311 describe the electronic 
components that allow the beneficiary to control two or more of the following motors from a single interface 
(e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power 
recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a 
function selection switch which allows the beneficiary to select the motor that is being controlled and an 
indicator feature to visually show which function has been selected. This feature is covered when 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 electrical connector to control one 
power feature. Our reviewer says that the requested controller is medically necessary. Our physician reviewer 
found the enrollee cannot weight bear through the right upper extremity due to a history of trauma due to a 
motor vehicle accident. He requires assistance with transfers and is noted to have 0/5 motor strength in the left 
upper extremity. The enrollee cannot perform pressure relief independently due to weakness and requires a 
power wheelchair with power tilt for adequate pressure relief and positioning. The complexity of his seating 
and positioning needs necessitates a more complex group 3 power wheelchair base. The requested controller is 
necessary to operate the group 3 power wheelchair base and the power tilt option. 
 
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 electrical connector to control one power feature have been met. Therefore, 
we decided that the Plan has to pre-approve an electrical connection to control one power feature through the 
wheelchair controller (E2310) for an approved power wheelchair.  
 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.