Persius/hicric huggingface dataset:
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 the enrollee needs to be transferred to the 
LTACH to regain maximum/prior level of functioning and to continue a multi-disciplinary approach to care. 
The Plan denied your request. The Plan says admission to the 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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve certified translation or sign-language services - per visit 
(D999) and removal of impacted tooth - completely bony (D7240). 
 
You asked the Plan to pre-approve dental services. You say that you disagree with the denial of requested 
services. The Plan denied your request. The Plan says this service is not covered under your Plan. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Certified translation or sign-
language services - per visit (D999) and removal of impacted tooth - completely bony (D7240) are not covered 
under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D999 and D7240 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
certified translation or sign-language services - per visit (D999) and removal of impacted tooth - completely 
bony (D7240).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary because the 
enrollee is a fall-risk. The Plan denied your request. The Plan says the SNF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for protective restoration services (D2940) provided on January 
18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 protective 
restoration services (D2940) provided on January 18, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve the esophagogastroduodenoscopy (EGD). 
 
You asked the Plan to pre-approve the EGD. You say that the upper endoscopy is crucial in accurately 
diagnosing and treating the enrollee's medical condition. The Plan denied your request. The Plan says that the 
EGD is not medically necessary. 
 
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 EGD. Our reviewer says that the 
requested EGD is considered medically reasonable and necessary in this case. Our physician reviewer found 
that based on the medical records provided there is documentation that the EGD at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for the enrollee. Provided records in this case 
document upper abdominal symptoms with records showing a diagnosis of dysphagia in a patient over the age 
of 65. These symptoms and patient factors are generally considered indications for an EGD per the medical 
standard of care and the Social Security Act, Section 1862(a)1(A). 
 
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 EGD have been met. Therefore, we decided that the Plan has to pre-approve 
the esophagogastroduodenoscopy (EGD).  
 
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 placement of an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that an implantable loop recorder is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an implantable loop recorder. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an ILR. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implantable loop recorder (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 5, 2022, billed 
with codes 81225, 81227, 81231, 81232, 81291 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 5, 2022, billed with codes 81225, 81227, 81231, 81232, 81291 and 81238.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L1 to L2 kyphoplasty (22514) and L1-L2 posterior 
lumbar interbody fusion (PLIF) (22630, 20931, 22840, 22853). 
 
You asked the Plan to pre-approve an L1 to L2 kyphoplasty. You say that the requested procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says there is no documented osteoporotic 
compression fracture by advanced imaging. 
 
The Plan follows Medicare rules. Medicare rules say that The rules state that kyphoplasty (PKP) is covered in 
patients with osteoporotic vertebral compression fracture (VCF) may be covered when acute or subacute VCF 
is present, based on symptom onset, and documented by advanced imaging. 
 
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 L1 to L2 kyphoplasty. Our reviewer 
says that the requested kyphoplasty at L1 to L2 is not medically necessary. Our physician reviewer found the provided imaging from June 8, 2023, does not corroborate any osteoporotic fractures at L1 to L2. Therefore, 
the reviewer found that the requested procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an L1 to L2 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an L1 to L2 kyphoplasty (22514) and L1-L2 posterior lumbar interbody fusion 
(PLIF) (22630, 20931, 22840, 22853).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service January 9, 
2023.  
 
You asked the Plan to pay for procedure code 76642. You say that the claim is billed correctly and should be 
paid. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 and 87653 billed for date of service 
December 6, 2022. 
 
You asked the Plan to pay for procedure code 87481 and 87653. The Plan denied your request. The Plan says 
payment for code 87481 and 87653 are bundled into payment for code 87801. The Plan says the XU modifier 
is not supported by medical records. 
 
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 87481 is a column II code to column I code 87801. This code has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
For code 87653, the CPT Code Manual definition is Streptococcus, group B, amplified probe technique. 
We asked our coder 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 code 87653. Our reviewer says that the criteria for coverage 
have not been met. Our reviewer found the procedure was reported with modifier XU, which indicates an 
unusual non-overlapping service. The laboratory report does not include documentation to support an unusual 
non-overlapping service.  CPT 87801 represents multiple organisms, and includes CPT 87653 when multiple 
procedures are performed. Therefore CPT 87653 XU cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87481 and 87653 billed for date of service December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2), Biologic 
materials to aid in soft and osseous tissue regeneration (D4265 x 1), immediate mandibular partial denture 
(D5222 x 1) and immediate maxillary partial denture (D5221 x 1). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 pre-approve 
guided tissue regeneration (D4266 x 2), Biologic materials to aid in soft and osseous tissue regeneration 
(D4265 x 1), immediate mandibular partial denture (D5222 x 1) and immediate maxillary partial denture (D5221 x 1).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, E0995. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has right side hemiplegia 
and is wheelchair bound. The Plan denied your request. The Plan says replacement items are never approved 
for new wheelchairs. 
 
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 E0995 is wheelchair accessory, calf rest/pad, replacement 
only, each. We find that a calf rest is included in the basic package of the approved power wheelchair. 
Replacement items are not covered on initial issue of a power wheelchair. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve wheelchair accessory, E0995.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax associated with medical equipment you 
purchased on January 25, 2023. 
 
You asked the Plan to pay for the sales tax. You say that your doctor told you to submit code E1038 for this 
item. The Plan denied your request. The Plan says sales tax is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make any additional payment 
for sales taxes. Therefore, we decided that the Plan does not have to pay for the sales tax associated with 
medical equipment you purchased on January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 6 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 6 months. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a ventilator for 6 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records document 
that the home ventilator is being requested for use in a volume assured pressure support mode (TTV-VAPS) 
with auto-EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial 
and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator for 6 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 6 months (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of right eyebrow ptosis (67900). 
 
You asked the Plan to pre-approve repair of right eyebrow ptosis. You say that this is medically necessary. The 
Plan denied your request. The Plan says records do not show that there is a margin reflex distance of 2.0 
millimeter or less on the right eye. 
 
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 repair of right eyebrow ptosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the marginal reflex distance (MRD1) for the right eye is not less than 2mm, 
and therefore the surgery is not considered functional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repair of right eyebrow ptosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve repair of right eyebrow ptosis (67900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you ask for 
reversal of the denial as the attached documentation speaks to the enrollee clinical presentation and the need for 
pneumatic compression. The Plan denied your request. The Plan says the enrollee does not meet the LCD 
criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0657).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug, Ondansetron Tab 8mg. 
 
You asked the Plan to pre-approve drug, Ondansetron Tab 8mg. Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the 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 drug, Ondansetron Tab 
8mg.