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

 
We decided that the Plan does not have to pay for procedure code 93018 billed for March 20, 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 code 93018 is 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 93018 is cardiovascular stress test using maximal or 
submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological 
stress; interpretation and report only.  

We find that CPT code 93018 is not supported in the medical record. Specifically, there is no documentation of 
an interpretation and report only for a cardiovascular stress test using maximal or submaximal treadmill or 
bicycle exercise with continuous electrocardiographic monitoring and/or pharmacological stress. 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 code 93018 billed for March 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93279 billed for date of service May 20, 2022. 
 
You asked the Plan to pay for code 93279. You say that this claim meets all Medicare coverage guidelines. The 
Plan denied your request. The Plan says you billed with an inappropriate pair of diagnoses on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used 
when two conditions cannot occur together, such as a congenital form versus an acquired form of the same 
condition. 
 
In this case, you billed with the following diagnoses: Z95.0 (presence of cardiac pacemaker), and Z45.010 
(encounter for checking and testing of cardiac pacemaker pulse generator [battery]).  According to the code 
tables that Medicare publishes, diagnosis code Z95.0 lists code Z45.010 as an Excludes1 code.  This means that 
these two diagnosis codes should not be billed together on the same claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 93279 have not been met. Therefore, we decided that the Plan does not have to pay for code 
93279 billed for date of service May 20, 2022.
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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement; however, the documentation does not support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least three (3) visits weekly to regain or maintain your functional status. You can receive 
further services 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that these services should be paid. The Plan 
denied your request. The Plan says payment for code 99233 is bundled into payment for code 99223. 
 
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 99233 is a column II code to column I code 99223 with a modifier indicator of 0. The Column I code was paid on a 
separate claim to the same provider. 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 99233 billed for date of service October 18, 2022.
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 enrollee will benefit and improve 
with this level of care and their needs are unable to be met remotely. The Plan denied your request. The Plan 
says the enrollee's medical needs are being met in the current setting. 
 
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 enrollee appears to be improving but is still unstable and requires additional acute 
care services at the current facility until more stable and appropriate for transfer. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Completion of treatment at the 
current facility is 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: 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's medical needs. The Plan denied your request. The Plan says the enrollee's care can be provided in 
the current inpatient hospital. 
 
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 enrollee appears to be stabilizing but it is not clear if they are able to wean yet. 
The enrollee requires additional acute care services at the current facility until more stable and appropriate for 
transfer. The enrollee does not require services at the LTACH that are not already available at the current 
facility. Completion of treatment at the current facility is 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer found there is no documented trial and failure of physical 
therapy (PT). More conservative measures are 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyalgan (J7321).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance cholangiopancreatography (MRCP). 
 
You asked the Plan to pre-approve the requested MRCP. You say that this imaging is medically required. The 
Plan denied your request. The Plan says that the criteria for this imaging have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested MRCP. Our reviewer 
says that the requested MRCP is considered medically reasonable and necessary at this time. Our physician 
reviewer found the enrollee has decompensated cirrhosis, and the requested MRCP is requested as part of a 
phase 1 liver transplant evaluation. As such, the requested exam is necessary to evaluate the hepatobiliary tree 
prior to further consideration of liver transplant in this enrollee with decompensated cirrhosis. Such evaluation 
will be necessary to evaluate the pancreas, pancreatic duct and bile ducts prior to transplantation. 
 
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 requested MRCP have not been met. Therefore, we decided that the Plan 
has to pre-approve magnetic resonance cholangiopancreatography (MRCP).  
 
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 pre-approve a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity.  
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee (L5852, L5845, L5848, L5856). 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the enrollee meets the requirements for 
the proposed prosthesis. The Plan denied your request. The Plan says that the requested microprocessor knee is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
is covered for beneficiaries whose functional level is 3 or above. 
 
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 microprocessor knee. Our reviewer 
says that a microprocessor knee is medically necessary. Our physician reviewer found the provided 
documentation more than supports that the enrollee is a K3 ambulator. Therefore, the reviewer found that the 
request for a microprocessor knee 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 a microprocessor knee have been met. Therefore, we decided that the Plan has 
to pre-approve a microprocessor knee (L5852, L5845, L5848, L5856).  
 
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 pre-approve the Tempus xT panel provided on November 14, 2022. 
 
You asked the Plan to pre-approve the Tempus xT panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage of this test, which also is not approved by the Food and Drug Administration (FDA) for 
the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Tempus xT panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had an elevated mean corpuscular volume (MCV) level for whom 
Tempus xT testing for myelodysplastic syndrome was provided. This test was sent prior to receiving results on 
other testing to rule out other causes. The test was not reasonable or medically necessary at the time it was 
sent.  
 
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 Tempus xT panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Tempus xT panel provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outer surface protective covering for a lower limb 
prosthesis. 
 
You asked the Plan to pre-approve outer surface protective covering. You say that extra covering for your 
prosthesis is necessary. The Plan denied your request. The Plan says the records do not show that a standard 
covering will not meet your needs. 
 
The Plan follows Medicare rules. Medicare rules state that an outer surface protective covering is used for 
harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of 
protection that is afforded by a standard covering. 
 
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 outer surface protective covering. Our 
reviewer says that you do not meet criteria for a protective covering. Our physician reviewer found the state of 
your residence is not a harsh living environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outer surface protective covering have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an outer surface protective covering for a lower limb prosthesis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty represented by CPT code 22513. 
 
You asked the Plan to pre-approve T12 Kyphoplasty. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is only covered for certain indications. 
 
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 T12 kyphoplasty. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of T12 compression fracture. The magnetic resonance 
imaging shows only 5% height loss and there is no documented trial of bracing. Therefore, the enrollee does 
not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 Kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty represented by CPT code 22513.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 6 additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of 6 
additional PT visits. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that the requested therapy services are reasonable and medically necessary. Our physician reviewer found that 
based on a review of the documentation additional therapy was requested for the enrollee's low back pain. 
Records show the enrollee has chronic pain and impaired function. Additional visits are medically necessary 
and reasonable. 
 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve 6 additional PT visits. 
  
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve 200 units of Botox. 
 
You asked the Plan to pre-approve 200 units of Botox. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that botulinum toxins (Botox, Dysport, Xeomin and 
Myobloc), will be considered medically reasonable and necessary when administered for treatment of certain 
FDA-labeled indications and Off-label indications.  

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 200 units of Botox. Our reviewer says 
that the services are medically necessary. Our physician reviewer found current FDA guidelines approving 
Botox for the treatment of neurogenic detrusor overactivity (NDO) specify that a dose of 200 U of Botox 
should be used. Although many clinicians have until now routinely used a 300 U Botox dose in catheter-
dependent NDO patients, recent data suggests no significant benefit to the higher dosing, supporting the FDA 
guidelines. In our practice we currently administer an intra-detrusor dose of 200 to 300 U in NDO patients and 
100 U to 150 U in idiopathic detrusor overactivity (IDO) patients. The review indicates that the requested units 
are medically necessary and reasonable based on the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 200 units of Botox have been met. Therefore, we decided that the Plan has to 
pre-approve 200 units of Botox.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional hours of neuropsychological testing (codes 
96137 x4 and 96139 x4). 
 
You asked the Plan to pre-approve 4 additional hours of neuropsychological testing. You say that you would 
like this case to be re-reviewed for neuropsychological testing under the enrollee's medical benefits. The Plan 
denied your request. The Plan says there is no documentation explaining why extended testing time is 
medically necessary beyond the previously approved hours. 
 
The Plan follows Medicare rules. Medicare rules say that typically, psychological testing will require from four 
(4) to six (6) hours to perform, including administration, scoring and interpretation. 
 
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 4 additional hours of 
neuropsychological testing. Our reviewer says that 4 additional hours of neuropsychological testing is not 
medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee does not 
present an explanation for increased neuropsychological testing beyond what was approved. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional hours of neuropsychological testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 4 additional hours of neuropsychological testing (codes 
96137 x4 and 96139 x4).