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

 
We decided that the Plan does not have to pay for laboratory services provided outside of the United States on 
October 18, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you would like reimbursement for these 
medical expenses. The Plan denied your request. The Plan says services received outside of the country are 
only covered when they are considered urgent or emergent. There is no evidence that the services at issue were 
not routine. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, these services were performed outside of the 
United States and were not urgent or emergent. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided outside of the United States on October 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the insertion of a spinal distraction device . You say that you are having 
trouble walking and has a herniated disc. You say you are having trouble walking which make you a fall risk. 
The Plan denied your request. The Plan says the insertion of a spinal distraction device is not medically 
necessary. The Plan says the device has not been shown to be safe and effective for treatment of your 
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 pre-approve the insertion of a spinal distraction 
device. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous distraction devices are experimental, and more research is 
needed. 
 
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 insertion of a spinal distraction device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on October 31, 2022, billed with 
procedure code 76937-26. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this add on code was billed without an appropriate 
primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the testing services provided have been 
met. Specifically, no medical records for this date of service have been provided for review. Therefore, we 
decided that the Plan does not have to pay for testing services provided on October 31, 2022, billed with 
procedure code 76937-26.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the excision or transposition of pterygium with graft. 
 
You asked the Plan to pre-approve the excision or transposition of pterygium with graft. You say that the 
surgery is medically necessary.  The Plan denied your request. The Plan says that  the eye surgery is not 
medically necessary. The Plan says that there is insufficient healthy tissue to create a conjunctival autograft.  
 
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 excision or transposition of 
pterygium with graft. Our reviewer says that the requested service is considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has bilateral central pterygium causing 
irregular induced astigmatism. The pterygium excision with graft was recommended and medically necessary. 
Medicare approves the use of amniotic membrane for wound healing during pterygium surgeries.  
 
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 excision or transposition of pterygium with graft have been met. Therefore, 
we decided that the Plan has to pre-approve the excision or transposition of pterygium with graft.  
 
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 DecisionDx-SCC testing rendered on April 5, 2023. 
 
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 were 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the use of molecular tests such as the 
DecisionDx-SCC test is not the standard of care for determining treatment of squamous cell carcinoma. The testing was not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDx-SCC testing rendered on April 5, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 ESI. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has chronic low back pain with radiculopathy. The enrollee had a trial of 
conservative therapy of both physical therapy and chiropractic without any sustained pain relief. Therefore, the 
request is medically reasonable and 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 ESI have been met. Therefore, we decided that the Plan has to pre-approve 
an ESI.  
 
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: Favorable

 
We decided that the Plan has to pre-approve a microprocessor controlled hydraulic knee (L5828, L5845, 
L5848, L5850, L5856, L5930) and flex-walk style foot with axial and multi-axial rotation units (L5981, L5984, 
L5986). 
 
You asked the Plan to pre-approve the prosthetic components. You say that the requested prosthetic features 
are medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be met by 
less complex components. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature. 
 
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 prosthetic components. Our 
reviewer says that the requested features are medically necessary. Our physician reviewer found Medicare rules 
state that it is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be 
strictly bound by functional level classifications. This bilateral amputee requires sophisticated componentry in 
order to safely ambulate in any setting at all. The requested microprocessor knee, flex-walk foot, and all 
addition codes requested, are among the class of components needed by a Beneficiary such as this in order to 
have mobility that is appropriately dynamic and also stable. 
 
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 prosthetic components have been met. Therefore, we decided that the Plan 
has to pre-approve a microprocessor controlled hydraulic knee (L5828, L5845, L5848, L5850, L5856, L5930) 
and flex-walk style foot with axial and multi-axial rotation units (L5981, L5984, L5986).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection 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. an epidural steroid injection is not 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 injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the enrollee had 80% 
pain relief after the epidural steroid injection on July 5, 2023. However, three months have not passed since the 
last epidural steroid injection. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0747). 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that this device is medically necessary. 
The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a bone growth stimulator is covered for failed fusion 
of a joint other than in the spine where a minimum of nine months has elapsed. 
 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 bone growth stimulator. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found the patient 
has a foot fracture. Not enough time has passed since the fracture for it to be determined a nonunion. At least 
nine months must pass. 
 
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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no documentation of at least 50% sustained improvement in pain relief and/or 
improvement in function measured from the enrollee's baseline for at least three months from the previous 
epidural steroid injection. Therefore, the criteria for coverage have not been 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient right total hip replacement. 
 
You asked the Plan to pre-approve the outpatient right total hip replacement. You say that you would like this 
case to be reviewed again, taking into consideration the documented physical therapy notes that demonstrate 
several weeks of conservative treatment.  The Plan denied your request. The Plan says the right hip 
replacement surgery is not medically necessary. The Plan says the enrollee has not completed six weeks of 
physical therapy.  
 
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 outpatient right total hip 
replacement. Our reviewer says that the requested service is not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee was being treated for osteoarthritis of the right hip. The documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative 
care measures is not evident. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the requested right total hip arthroplasty 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 the outpatient right total hip replacement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the outpatient right total hip replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on April 10, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 18, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 81456 billed for date of service January 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service April 29, 
2023.   
You asked the Plan to pay for procedure code 99284. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99284 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99284 billed for date of service April 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service January 4, 
2023. 
 You asked the Plan to pay for procedure code 87640. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 
87641. 
 
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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service January 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to decrease their risk for readmission and to promote health improvement. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for 
transfer to an LTACH. 
 
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 the record indicates that the enrollee remains critically ill with ongoing medical 
issues and still requires acute care services. 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 they are not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on February 21, 2023, billed with 
procedure code 71271-GZ. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says this is a non-covered service 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines submitted with the GZ modifier are 
automatically denied.  
 We looked at the file and Medicare rules. The service was billed with a GZ modifier. Claim lines with GZ 
modifier are automatically denied as non-covered services. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for testing services provided on February 21, 2023, billed with procedure code 
71271-GZ.