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

 
We decided that the Plan does not have to pre-approve seat elevator, electronic connection between two 
systems, expandable controller, expandable controller harness, and transit option. 
 
You asked the Plan to pre-approve seat elevator, electronic connection between two systems, expandable 
controller, expandable controller harness, and transit option. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare rules also say that power wheelchair accessories are only 
covered for certain indications. A power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested seat elevator is 
specifically not covered. The documentation shows that the enrollees upper limb strength and function are 
adequate for the enrollee to be able to control the power options using their own switches which are included in 
the allowance for the approved power options. The requested transit option at issue in this appeal is for use 
outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for 
use outside the home. Therefore, we decided that the Plan does not have to pre-approve seat elevator, electronic 
connection between two systems, expandable controller, expandable controller harness, and transit option.
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 the enrollee is not ready to go home and would 
benefit from more physical therapy and inhouse dialysis. The Plan denied your request. The Plan says based on 
Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee is medically stable and does not need physical medicine and a 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. The enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF.  It is unlikely that the 
enrollee will tolerate and make a significant functional recovery in a reasonable period of time in an IRF. While 
the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehabilitation needs 
can be provided in a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic preventive examination (99397). 
 
You asked the Plan to pre-approve a periodic preventive examination. You say that the services are necessary. 
The Plan denied your request. The Plan says the requested service is a status N code and therefore, is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a periodic preventive examination have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a periodic preventive examination (99397).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system tie-down kit. 
 
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 the item is not covered. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a transit system tie-down kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service March 14, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 
99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service March 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve Vertiflex Superion Interspinous device. 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 Vertiflex Superion Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region 
with neurogenic claudication. The enrollee presented with low back pain with left leg numbness and right leg 
pain. The enrollee has intermittent neurogenic claudication due to lumbar spinal stenosis that is moderate at the 
L4-5 level manifesting his low back pain, left leg numbness, and right leg pain. The pain today is rated at one 
out of 10. The exam reveals numbness in the enrollees left leg when the enrollee rises from a seated to a 
standing position. This improves when the enrollee sits back down.  
 However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the enrollee does not meet criteria for 
the requested Vertiflex Superion interspinous spacer at L4-5. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stiolto. 
 
You asked the Plan to pre-approve Stiolto. You say that the drug is medically necessary. The Plan denied your 
request. The Plan says Stiolto is a benefit exclusion under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stiolto.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 6, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile needles provided on August 11, 2022. 
 
You asked the Plan to pay for the sterile needles. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
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 A4215 is needle, sterile, any size, each. 
 
We find that CPT code A4215 is not supported in the medical record. Specifically, this code has a status code 
of "X". This means this is a statutory exclusion. These codes represent an item or service that is not in the 
statutory definition of physician services for fee schedule payment purposes. This code is not payable as 
billed.  Based on this information, we decided that Medicare rules for coverage of the sterile needles have not been 
met. Therefore, we decided that the Plan does not have to pay for the sterile needles provided on August 11, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox 100 unit injections. 
 
You asked the Plan to pre-approve Botox injections. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that botulinum toxin for chronic anal fissure may be 
considered for the patient who has not responded satisfactorily to conservative treatment. 
 
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 Botox injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is insufficient support in the documentation that the Botox at issue in this case meets all of 
Medicare's LCD criteria for medically reasonable and necessary and safe and effective for the enrollee. 
Provided medical records do not document evidence of chronic anal fissure on examination of the enrollee or in 
the assessment of the enrollee in the provided visit notes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Botox 100 unit injections.
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 July 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. 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 July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953), and guided tissue regeneration - resorbable barrier, per site (D4266) provided on September 23, 2022. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation - per site (D7953), and guided 
tissue regeneration - resorbable barrier, per site (D4266). You say that you were told to file a claim under 
medical emergency for service codes D7953 and D4266. You also say that you paid out-of-pocket for the 
dental services and are asking for reimbursement. The Plan denied your request. The Plan says these services 
are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft for ridge preservation - per site (D7953), and guided tissue regeneration - resorbable barrier, 
per site (D4266) provided on September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service June 24, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 87481, 
87653, and 87798 are bundled into payment for code 87801. 
 
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 codes 
87481, 87653, and 87798 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. The records provided do not support the use of modifier 91 billed with 
code 87798. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, and 
87798 billed for date of service June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 provided on August 10, 2022. 
 
You asked the Plan to pay for procedure code G0481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0481 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records support that 
more than 14 drug classes were tested. Based on this information, we decided that Medicare rules for coverage 
of procedure code G0481 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0481 provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
and harness upgrade, electronic connection, and footplate gel pad. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that an expandable controller is used to control multiple power options. 
 
The requested power seat elevation system and footplate gel pad do not serve a purpose that is primarily 
medical in nature. The expandable controller and harness upgrade with electronic connection are not needed to 
control the approved power switches. Therefore, we decided that the Plan does not have to pre-approve a power 
seat elevation system, expandable controller and harness upgrade, electronic connection, and footplate gel pad.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), the electronic 
connection between wheelchair controller and two or more power seating system motor (E2311), a harness 
(E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you have attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says although there are three approved power options/features on this wheelchair 
(tilt, recline, PELR), there is not a medical need to control these power options/features through the joystick. 
The enrollee does not meet criteria for the power options. 
 
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 wheelchair accessories. 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 a neurologic disorder with functional deficits. Criteria for a power 
wheelchair are met. The requested electrical accessories are not medically necessary as the enrollee does have 
use of the upper extremity and can operate and control the power options using the switches that are included in 
the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system (E2300), the electronic connection between 
wheelchair controller and two or more power seating system motor (E2311), a harness (E2313) and an 
expandable controller (E2377).
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 the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF. The enrollee's needs can be provided at a 
lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with home health 
care, or in a long-term care setting. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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.