Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on June 12, 2023, billed with procedure 
codes 36561-RT and 77001-26. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
codes. 
 
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 
codes 36561-RT and 77001-26 is fluoroscopic guidance for central venous access device placement, 
replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and 
catheter manipulation, any necessary contrast injections through access site or catheter with related venography 
radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List 
separately in addition to code for primary procedure), and insertion of tunneled centrally inserted central 
venous access device, with subcutaneous port; age 5 years or older. 
 
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 the practitioner services provided. Our reviewer says that 
documentation does support the billed codes. Our reviewer found that primary procedure CPT 36561 is 
supported in the medical record submitted, as an addendum was performed to confirm catheter termination. 
Therefore, both procedures should be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on June 12, 2023, billed with procedure codes 36561-RT and 
77001-26.  
 
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 traction equipment, cervical, free-standing stand/frame, 
pneumatic, applying traction force to other than mandible (E0849) provided June 9, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that the doctor requested a cervical traction 
device to help assist with mobility. Please reprocess the claim. The Plan denied your request. The Plan says the 
diagnosis on the records does not match the diagnosis on the prescription.  
 
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 traction equipment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support the device is being used for one of the 
recommended uses for the cervical traction device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the traction equipment have not been met. Therefore, we decided that the Plan 
does not have to pay for traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction 
force to other than mandible (E0849) provided June 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reactiv8 nerve stimulator. 
 
You asked the Plan to pre-approve Reactiv8. You say that Reactiv8 will be more beneficial for the enrollee's 
condition than any of the available standard therapy. The Plan denied your request. The Plan says the clinical 
value and effectiveness have not been demonstrated. 
 
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 Reactiv8. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy. There are no clinical practice guidelines that support 
the use of this device. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reactiv8 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reactiv8 nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered from February 14, 2023, to February 20, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee has Parkinsons 
Disease, and was seen and treated in the hospital between February 14, 2023, to February 20, 2023. The 
documentation from these dates describes the enrollee as presenting with lethargy and recent shingles diagnosis 
and was admitted with suspected viral encephalitis. The enrollee was started on IV fluids, acyclovir, and 
antibiotics. Although the documentation included appropriate history and examination, the documentation did 
not sufficiently support a high level of decision-making or a duration of the encounter being 75 or more 
minutes as required for CPT 99223. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99223) rendered from February 14, 2023, 
to February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthosis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough medical evidence that shows that this device is reasonable and 
necessary to improve function of the arm. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on April 11, 2023. 
 
You asked the Plan to pay for initial hospital care (99223). You say that the services were necessary for the 
treatment of the enrollee's condition and procedure code 99223 accurately reflects the treatment provided. The 
Plan denied your request. The Plan says the medical records submitted do not support high level of medical 
decision making or total time required for the code 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 initial hospital care (99223). Our reviewer says that 
procedure code 99223 is not supported. Our reviewer found that the documentation does not support a high 
level of medical decision-making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) provided on April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty procedure (27447). 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that a total knee arthroplasty is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a total knee arthroplasty 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 a total knee arthroplasty. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, 
less invasive conservative-care measures is not evident in the case record. The provided documentation does 
not support a trial and failure of any formal physical therapy or of Hyalgan injections. Moreover, the objective findings do not corroborate significant deficits. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical 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 a total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty procedure (27447).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate surgery (37243). 
 You asked the Plan to pre-approve prostate surgery. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 prostate surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found prostatic arterial embolization (PAE) is not medically reasonable and necessary in this case. 
Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign 
prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve prostate surgery (37243).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found inpatient admission is not medically necessary and the recommended 
treatment can be performed at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vtama cream. 
 
You asked the Plan to pre-approve Vtama. You say that the requested drug is a medical necessity for the 
enrollee. The 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Vtama 
cream.  
 
Benefits for Vtama may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a PET scan.  
 
You asked the Plan pre-approve the PET scan. You say that the requested imaging is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 pre-approve the PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee is suspected of having Dementia 
with Lewy body disease (DLB) or similar related to their Parkinson's Disease. AD is only mentioned as a 
differential diagnosis. In such a case, the enrollee would not meet the base NCD requirement of meeting 
diagnostic criteria for both AD and FTD. This request would not meet the NCD requirements for coverage.  
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sling for a patient lift (E1399). 
 
You asked the Plan to pre-approve a lift sling. You say that the requested item is a necessity for your care. The 
Plan denied your request. The Plan says rules for coverage for DME have not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a sling or seat (E0621) as part of an approved patient lift (E0630). A sling or seat 
(E0621) as part of an approved patient lift (E0630) serves the same purpose as a lift sling.  
 Therefore, we decided that the Plan does not have to pre-approve a sling for a patient lift (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like to request reconsideration of 
the denied shower chair and that the services requested are medically necessary. The Plan denied your request. 
The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code G2212 rendered on May 15, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support two units of this code. 
 
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 G2212 is "Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been 
selected using total time on the date of the primary service; each additional 15 minutes by the physician or 
qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 
99205, 99215, 99483 for office or other outpatient evaluation and management services) (do not report g2212 
on the same date of service as 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 
minutes)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found two units of procedure code G2212 
was rendered on May 15, 2023. However, two units would match with 104-118 minutes duration for this 
encounter, which is not justified in the documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code G2212 rendered on May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 1 standard, portable, 
sling/solid seat and back, patient weight capacity up to and including 300 pounds (K0813) and a power 
mobility device, not coded by DME PDAC or does not meet criteria (K0899). 
 
You asked the Plan to pre-approve a power wheelchair and mobility device. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says in order to approve the 
services requested, the Plan needs more information, such as a standard written order (SWO). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 The file shows that in order to approve this request, additional information is needed. A SWO, an on-site 
evaluation of the enrollees home, and a history of prior conservative care is needed. This means that Medicare 
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to 
and including 300 pounds (K0813) and a power mobility device, not coded by DME PDAC or does not meet 
criteria (K0899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultraviolet (UV) phototherapy wand (E0691), provided on May 23, 2023.
You asked the Plan to pay for the ultraviolet (UV) phototherapy wand. You say that the item is medically necessary. The Plan denied your request. The Plan says the records provided do not show that the enrollee has any skin rashes caused by psoriasis. In addition, the records do not show that the enrollee has medical and other factors that justify the need home phototherapy, as opposed to office-based phototherapy, or treatment at an alternative site.
The Plan must follow Medicare rules. Medicare rules say that UV light therapy systems are covered for selected patients with generalized intractable psoriasis. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultraviolet (UV) phototherapy wand have not been met. Therefore, we decided that the Plan does not have to pay for the ultraviolet (UV) phototherapy wand (E0691), provided on May 23, 2023.