Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomographic angiography (CTA) of the chest (71275). 
 
You asked the Plan to pre-approve a CTA of the chest. The Plan denied your request. The Plan says that this 
request cannot be approved because the records do not show that the CTA is needed for recurrent or persistent 
signs or problems such as shortness of breath, new results of a blood test that show it has stayed high or gone 
back up, or heart test results that show the right side of the enrollee's heart is not working well. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CTA of the chest. Our reviewer says 
that a CTA of the chest is reasonable and necessary for the enrollee. Our physician reviewer found the 
administration of Eliquis is not without risk and continuation of this drug will depend on the results of a follow-
up CTA of the chest. Our reviewer found if the clots have resolved the drug will be discontinued, however, if 
the clot remains the drug will likely be continued. Our physician reviewer also found that the requested CTA 
will be the determining factor and should be approved. 
 
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 CTA of the chest have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomographic angiography (CTA) of the chest (71275).  
 
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 pneumatic compression device (PCD) provided from 
February 1, 2022, to February 22, 2022. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says the records do not support 
the PCD. 
 
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.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the PCD provided in this case. The provided medical records do not indicate ordering or using this PCD for treatment. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the pneumatic 
compression device (PCD) provided from February 1, 2022, to February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) and a power seat elevation system (E2300) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection and a 
power seat elevation system. You say that the requested items are a medical necessity for the enrollee. 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. The rules also say that a power seat elevation feature (E2300) and power standing 
feature (E2301) are non-covered because they are not primarily medical in nature. 
 
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 expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that 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 an expandable controller with harness and electronic connection and a power 
seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller (E2377) with harness (E2313) and electronic connection (E2311) and a power seat 
elevation system (E2300) for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says clinical information 
was not submitted showing medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 IRF care have been met. Specifically, 
medical records were not submitted for review. Without medical records, medical necessity cannot be 
established. Therefore, we decided that the Plan does not have to pre-approve inpatient rehabilitation facility 
(IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0398 billed for date of service April 2, 
2022. 
 
You asked the Plan to pay for procedure code A0398. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is statutorily excluded for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A0398 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A0398 is statutorily excluded from payment. Based on this information, we decided that 
Medicare rules for coverage of procedure code A0398 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A0398 billed for date of service April 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external electrocardiographic recording (93242 and 
93244). 
 
You asked the Plan to pre-approve external electrocardiographic recording. You say that you would like to 
appeal these services because you would like to know what is wrong with your heart. The Plan denied your 
request. The Plan says you have Supraventricular tachycardia, and do not meet the guideline as there was no 
note from the doctor that you have a heart arrhythmia that needs further workup. The Plan also says this service 
has been denied because it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
 
  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 external electrocardiographic recording. 
Our reviewer says that the external electrocardiographic recording is not reasonable and necessary for you. Our 
physician reviewer found you have a history of chest pain, for which a stress test was performed, with no 
evidence of cardiac ischemia. Incidental ectopic beats were noted, however, and a 2-day ambulatory monitor 
performed, also showing ectopic beats in singlets and salvos. Our reviewer found that as such, guidelines 
would not support a need for 7-day ambulatory electrocardiogram (ECG) monitoring in this setting. Our 
physician reviewer also found that there was insufficient documentation to support the medical necessity for a 
7-day ambulatory ECG monitor in your 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 external electrocardiographic recording have not been met. Therefore, we 
decided that the Plan does not have to pre-approve external electrocardiographic recording (93242 and 93244).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail fungal polymerase chain reaction (PCR) testing (87481, 
87798, 87801) provided February 3, 2022. 
 
You asked the Plan to pay for the nail fungal PCR testing. You say that the enrollee presented at the provider's 
office complaining of fungal infection of toenail and the procedure was performed to hasten definitive 
diagnosis and to efficiently treat the enrollees condition. The Plan denied your request. The Plan says the 
enrollee presented at the provider's office complaining of fungal infection of toenail and the procedure was 
performed to hasten definitive diagnosis and to efficiently treat the patient's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the nail fungal PCR testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that PCR testing for the diagnosis of onychomycosis is experimental/ investigational. 
There is insufficient scientific evidence in the current medical literature to indicate that this technology is as 
beneficial as the established alternatives. The review has determined that the items/services at issue in this case 
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 nail fungal PCR testing have not been met. Therefore, we decided that the 
Plan does not have to pay for nail fungal polymerase chain reaction (PCR) testing (87481, 87798, 87801) 
provided February 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 17 home health aide visits. 
 
You asked the Plan to pre-approve the aide services. You say that a home health aide is needed during the week 
while your spouse is at work. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found no medical notes 
from the enrollee's treating physician are provided documenting an order or need for skilled home health aide 
services. Based on the medical records provided there is no documentation that the home health aide services 
are reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. 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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 17 home health aide visits.
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 June 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. 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 June 27, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee has ongoing acute medical issues and 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules are not satisfied. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components, and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that the MyoPro is a covered 
device within the DME benefit category under Original Medicare. The Plan denied your request. The Plan says 
your request for the brand specific MyoPro Motion G Orthotic device is not a covered benefit and does not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro Motion G 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 Orthosis is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for this enrollee's condition or in widespread use for this enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity range of motion assist device, elbow, 
wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components, and 
accessories, custom fabricated (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (CPT code L5781). 
 
You asked the Plan to pre-approve the item. You say that this should be covered. The Plan denied your request. 
The Plan says the request under code L5781 for what is considered an experimental and investigational VASS 
exceeds the enrollee's need. 
 
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 item. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the literature reviewed indicates that further research is needed with clinical trials that recruit 
larger sample sizes and report long-term outcome data for the requested vacuum suspension system. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve addition to lower limb prosthesis, vacuum pump, residual limb volume management and 
moisture evacuation system (CPT code L5781).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83986 and 82570 billed for date of service 
May 31, 2022. 
 
You asked the Plan to pay for procedure codes 83986 and 82570. The Plan denied your request. The Plan says 
payment for codes 83986 and 82570 is bundled into payment for code 80307.  
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 
83986 and 82570 are column II codes to column I code 80307. 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 codes 83986 and 82570 billed for 
date of service May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. No TC 
billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, 
generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT code 85060 
furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare 
rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) 85060 billed for date of service July 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 3D image interpretation (76377) provided on August 15, 
2022. 
 
You asked the Plan to pay for the 3D image interpretation. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 76376 and 76377 must be performed in 
conjunction with the base imaging procedure. Medicare would expect the base imaging procedure to be billed 
on the same claim as code 76376 or 76377 the majority of the time. Codes 76376 and 76377 are allowed only 
when billed in conjunction with another computed tomography, magnetic resonance imaging or other 
tomographic modality procedure codes. 
 
We looked at the file and Medicare rules. No base radiology service was billed on the claim. Based on this 
information, we decided that Medicare rules for coverage of the 3D image interpretation have not been met. 
Therefore, we decided that the Plan does not have to pay for a 3D image interpretation (76377) provided on 
August 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal endoscopy rendered on July 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that postoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 31231 was related to and billed within 90 days of 
major surgical procedure 15733 billed on July 14, 2022. Payment for code 31231 is included in the global 
surgical payment. Therefore, we decided that the Plan does not have to pay for the nasal endoscopy rendered 
on July 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the smoking cessation services rendered on July 20, 2022. 
 
You asked the Plan to pay for these services. You say that you were told you would be reimbursed 80 percent 
of the cost. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. Te rules say that a drug and alcohol counselor is not eligible to 
participate in Medicare; however, the Plan has a supplemental benefit that covers smoking cessation 
counseling. 
 
We looked at the file and the Plan's rules. The file shows that the services were not performed by a counselor 
but by a hypnotist. Based on this information, we decided that Plan's rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the smoking cessation services 
rendered on July 20, 2022.