Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that you are requesting reconsideration and 
have provided medical records for review. The Plan denied your request. The Plan says a review of the current 
medical literature does not consider this service to be standard medical treatment for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a Cala Trio tremor stimulator device is not medically necessary per the Social 
Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. There is insufficient evidence in the literature that this device is 
effective for your tremor. The requested K1018 is not the standard of care for your tremor according to current 
guidelines. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93970) provided on June 12, 2022. 
 
You asked the Plan to pay for the duplex scan (93970). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the duplex scan (93970) 
provided on June 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Leqembi. 
 
You asked the Plan to pre-approve Leqembi. You say that coverage for this drug has become effective. The 
Plan denied your request. The Plan says the enrollee is not participating in an approved study or trial for this 
drug. 
 
The Plan must follow Medicare rules. Medicare rules say that monoclonal antibodies such as Leqembi directed 
against amyloid for the treatment of Alzheimers Disease are nationally non-covered outside of an approved 
study or trial.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of Leqembi.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0283 billed for date of service January 11, 
2023. 
 
You asked the Plan to pay for procedure code G0283. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this service was submitted with two 
diagnosis codes reporting different laterality, but a bilateral code exists for this condition. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, 
right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both 
the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0283 have not been met. Specifically, this service was billed with ICD-10-CM 
codes G56.01 (carpal tunnel syndrome, right upper limb) and G56.02 (carpal tunnel syndrome, left upper limb), 
indicating a bilateral condition. However, code G56.03 (carpal tunnel syndrome, bilateral upper limbs) exists 
and should have been used in this case. Therefore, we decided that the Plan does not have to pay for procedure 
code G0283 billed for date of service January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27760 rendered on October 12, 2022. 
 
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 Current Procedural Terminology (CPT) code 27760-LT (1 unit) remains 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 27760 is "Closed treatment of medial malleolus fracture; 
without manipulation." 
 
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 detailed documentation is not evident regarding the provider performing ongoing treatment to the left lower extremity. There were no follow-
ups clearly documented. He was to be non-weight bearing. Therefore, the records do not support that CPT 
27760: closed treatment of medial malleolus fracture; without manipulation was rendered in this case. 
 
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 procedure code 27760 rendered on October 12, 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 enrollee would not be appropriate for a lower 
level of care. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may require physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation care. There is not a reasonable expectation that the enrollee will be able to fully participate in - 
and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care as of September 10, 2023. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet criteria for inpatient psychiatric care. Our physician reviewer found it 
appears that the enrollee has reached maximum benefit from the inpatient stay. The enrollee is noted to be in no 
psychiatric distress and is eating and sleeping adequately. The progress notes do not indicate that the enrollee 
has been aggressive or attempted self-harm. There is no indication that the enrollee's psychiatric symptoms 
could not be managed 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care as of September 10, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 36556 rendered on September 9, 2022. 
 
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 that the records do not support the services 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 36556 is "Insertion of non-tunneled centrally inserted central venous catheter; 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 services. Our reviewer says that the service at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports that the 
services in question were rendered and appropriately coded. There is satisfactory documentation that a central 
line was placed in the internal jugular vein. There is satisfactory documentation that the line was placed 
centrally. As most central lines placed perioperatively are not placed under fluoroscopic guidance, the exact 
location of the tip cannot be documented, and it is not reasonable to require this information to justify billing.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 36556 rendered on September 9, 2022.  
 
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 contour next test strips. 
 
You asked the Plan to pre-approve contour next test strips. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says after several attempts, necessary 
information was not received that was requested from your provider. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of contour next test strips have been met. 
The records show that several attempts were made to request medical records and additional information from 
the provider, and they were not received. Therefore, we decided that the Plan does not have to pre-approve 
contour next test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 4, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that M54.14 has an Excludes1 note in relation to M50.123. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on January 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of silicone from face and lips provided on April 
27, 2023. 
 
You asked the Plan to pay for the removal of silicone from face and lips. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says the surgery provided was not medically 
necessary to correct or repair abnormal structures of the body caused by congenital defects, developmental 
abnormalities, trauma, infection, tumors, or disease to either, improve function; and/or to create a normal 
appearance to the extent possible.  
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 removal of silicone from face and lips. Our reviewer says that the criteria for coverage have not been met.  Our reviewer found the surgery in dispute 
was not required for the prompt repair of accidental injury or to improve the functioning of a malformed body 
member. The services provided were considered cosmetic in nature and were 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 the removal of silicone from face and lips have not been met. Therefore, we 
decided that the Plan does not have to pay for the removal of silicone from face and lips provided on April 27, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L4361) provided on January 10, 2023. 
 
You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines billed with codes without a KX, GA 
or GZ modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The claim line did not include a required modifier. Based on this 
information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we 
decided that the Plan does not have to pay for an orthosis (L4361) provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on January 24, 2023, 
billed with code G0483. 
 
You asked the Plan to pay for the drug testing as billed. You say that this was billed correctly.  The Plan denied 
your request. The Plan says the billed number of drug classes 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the lab report only shows 
results for 18 separately billable drug classes. Based on this information, we decided that Medicare rules for 
coverage of the drug testing as billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the definitive drug testing provided on January 24, 2023, billed with code G0483.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer. 
 
You asked the Plan to pre-approve a Vertiflex Superion interspinous spacer. 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 a Vertiflex Superion interspinous 
spacer. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Vertiflex Superion interspinous spacer at L4/5, in this case, 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 a Vertiflex Superion interspinous spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (72050, 72100, 72080, 99202, 99212, 
77071, 72040, 72020, 97012, 97112, & 99070) provided on March 15, 2023 to April 14, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules say that the Physician Fee Schedule Status 
Indicator B means that payment for covered services is always bundled into payment for other services 
 
The records show that the service at issue is not manual manipulation of the spine. Procedure code 99070 has a 
status indicator of "B" and payment is always bundled with another service. Therefore, we decided that the Plan does not have to pay for chiropractic services (72050, 72100, 72080, 99202, 99212, 77071, 72040, 72020, 
97012, 97112, & 99070) provided on March 15, 2023 to April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83721 billed for date of service April 28, 
2023. 
 You asked the Plan to pay for procedure code 83721. The Plan denied your request. The Plan says payment for 
code 83721 is bundled into payment for code 80061. 
 
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 83721 
is a column II code to column I code 80061. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83721 billed for date of service April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the enrollee would be more compliant on a CGM 
than on a glucometer. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria provided for a 
CGM requires low blood sugars or insulin use. This enrollee is not using insulin and is not having low blood 
sugars that we are told nor is the enrollee taking a medication that causes low blood sugars. While the CGM 
might help the enrollee comply with diet requirements as the provider states, the criteria for coverage are not 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).