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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the request 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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0481) provided on April 14, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was reported correctly. The Plan denied 
your request. The Plan says the code used to report the service provided is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0481 is drug test(s), definitive, 8-14 drug class(es), 
including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the record supports that 
drugs from more than 14 drug classes were tested in this case. There is another code which would report the 
services provided more accurately. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for definitive drug 
testing (G0481) provided on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95913 and 95886 billed for June 13, 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 procedure codes 95913 and 95886 are not supported. 
 
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 95913 is nerve conduction studies; 13 or more studies. 
The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for 
primary procedure). 
 We find that CPT codes 95913 and 95886 are not supported in the medical record. Specifically, there is no 
documentation of 13 or more nerve conduction studies were performed to support code 95913. Given that the 
primary procedure code 95913 is not supported, add-on code 95886 is also not supported. 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 procedure codes 95913 and 95886 billed for June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ImpediMed L-Dex bioimpedance spectroscopy (BIS) 
testing device (93702). 
 
You asked the Plan to pre-approve ImpediMed L-Dex device. You say that this test is necessary to monitor for 
lymphedema. You also say that the enrollee should not have to deal with non-coverage of this service. The Plan 
denied your request. The Plan says the requested testing 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 ImpediMed L-Dex device. Our 
reviewer says that the requested ImpediMed L-Dex devuce is not considered medically reasonable and 
necessary in this case. Our physician reviewer found management via bioelectrical impedance spectroscopy has 
been proposed as a way to implement early treatment of subclinical lymphedema to potentially reduce its severity. Bioimpedance devices for detection of lymphedema are considered investigational. Therefore, the 
reviewer found that the requested device is not 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 ImpediMed L-Dex device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ImpediMed L-Dex bioimpedance spectroscopy (BIS) testing device (93702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eyewear guarantee purchased on January 19, 2023. You asked the Plan to pay for an eyewear guarantee. You say that you disagree with the denial of the eyewear 
guarantee. The Plan denied your request. The Plan says that an eyewear guarantee is not covered.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when The Plan covers up to a $320 allowance for non-Medicare 
covered prescription eyewear. 
 
We looked at the file and the Plan's rules. An eyewear guarantee is not covered. Based on this information, we 
decided that the Plan's rules for coverage of an eyewear guarantee have not been met. Therefore, we decided 
that the Plan does not have to pay for an eyewear guarantee purchased on January 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 16, 2022, to 
February 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 16, 2022, to 
February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 28, 2022, to 
March 2, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services were ordered by a qualified physician who determined it was appropriate based on all of the facts upon 
presentation to the facility. You say that the claim should be reimbursed at the previously denied DRG. The 
Plan denied your request. The Plan says the records do not support diagnosis codes J96.21 and J96.22. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.21 - acute and chronic respiratory failure with 
hypoxia and J96.22 - acute and chronic respiratory failure with hypercapnia. 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 inpatient hospital services at the DRG originally billed. Our physician 
reviewer found the criteria for acute respiratory failure with hypoxia not met - no distress, no hypoxia recorded 
- or with hypercapnia. No elevated carbon dioxide (CO2) level recorded. The Plan has adjusted appropriately.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 28, 2022, to March 2, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve the DME. You say that you need the stimulator for spinal surgery. The Plan 
denied your request. The Plan says that this request is denied for lack of medical necessity. 
 
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 DME. Our physician reviewer 
found you do meet one of the required criteria listed in the LCD. The records do not show you have a failed 
spinal fusion where a minimum of nine months has elapsed since the last surgery. This service is following a 
multilevel spinal fusion surgery. This service is not following spinal fusion surgery where there is a history of a 
previously failed spinal fusion at the same site. The treatment plan included posterior decompressive 
laminectomy and posterolateral arthrodesis C5-C7 as well as anterior partial corpectomy at C5, C6, and C7 
with interbody arthrodesis and instrumentation C5-7. Therefore, this service will be following a multilevel 
spinal fusion surgery. 
 
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 DME have been met. Therefore, we decided that the Plan has to pre-approve 
an osteogenesis stimulator (E0748).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements based on the guidelines and the information we have, services needed may be 
provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0998 billed for date of service December 
10, 2021. 
 
You asked the Plan to pay for procedure code A0998. You say that this service was medically necessary and 
this claim was timely filed. The Plan denied your request. The Plan says the billed code is invalid 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 A0998 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A0998 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A0998 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A0998 billed for date of service December 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services to overcome 
mobility issues and address functional deficits. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that your current scooter is broken down. You 
need a scooter to get around. The Plan denied your request. The Plan says the medical information provided did 
not include a include a face-to-face evaluation or indicate that you have limited use of your upper body. You do 
not meet the Medicare guidelines for a power mobility device. 
 
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.  
 
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 power scooter. Our reviewer says that 
a power scooter is not medically necessary. Our physician reviewer found you have a mobility deficit but the 
documentation does not support that this deficit impairs your participation in mobility related activities of daily 
living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home.The 
April 12, 2023, primary care progress note states that you needs no help with activities of daily living (ADLs). 
The documentation does not reveal a gait evaluation, complete and detailed neuromuscular and 
musculoskeletal physical examination supporting why your condition is unable to be ameliorated by a walker, 
cane or manual 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 3, 
2022 to December 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 3, 2022 to December 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc 850. 
 You asked the Plan to pre-approve Genvisc 850. You say that Genvisc 850 is medically necessary. The Plan 
denied your request. The Plan says a trial of Euflexxa or Synvisc is required before alternatives can be 
considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Genvisc 850. Our reviewer says that 
this drug is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Genvisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc 850.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance for use 
with pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compressor, full leg segmental pneumatic appliance, and a 
trunk segmental pneumatic appliance. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652, is covered for the treatment 
of lymphedema extending onto the chest, trunk and/or abdomen when certain criteria are met. 
 
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 pneumatic compressor, full leg 
segmental pneumatic appliance, and a trunk segmental pneumatic appliance. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the pneumatic compression device and appliances at issue in this case meet all 
Medicare criteria for medically reasonable and necessary for the enrollee. Provided records in this case do not 
document lymphedema extending onto the chest, trunk and/or abdomen which has remained unresponsive to all 
other therapies. Records do not document trial and failure of at least four weeks of regular, daily, multiple-hour 
home usage of a basic pump after careful, in-person fitting, training and supervision by a technician who is 
skilled in and who regularly and successfully uses the appliance provided. 
 
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 pneumatic compressor, full leg segmental pneumatic appliance, and a trunk 
segmental pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667), and segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
17, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 17, 2022.