Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 1, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 1, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were 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 from 
September 1, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of September 1, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond September 1, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
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 from September 1, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 1, 
2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a BMP allograft. 
 
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 the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the BMP allograft is not approved by 
the Food and Drug Administration (FDA) for use in the posterior spine. It remains experimental for this use 
and is not the standard of care over the gold standard of an iliac crest. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a BMP allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L4 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific 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 L4 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding an acute/subacute compression fracture at L4. There is no indication of a progression of the 
body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is magnetic 
resonance imaging corroboration of other plausible causes of back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L4 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L4 kyphoplasty (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve zoledronic acid. 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that bisphosphonate injections (administered 
intravenously [IV]) will be considered medically reasonable and necessary when administered as outlined in 
the LCD rules listed in the Medicare rules section. The coverage of IV bisphosphonates must be supported in 
the medical record. 
 
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 reviewer says that 
the medication is not medically necessary. Our physician reviewer found a bone densitometry done on April 
12, 2022, showed findings were normal according to WHO (World Health Organization) criteria. The review 
has determined that the record does not show that the enrollee meets the criteria listed 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve zoledronic acid.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shroud model (K0108). 
 
You asked the Plan to pre-approve a shroud model. You say that you want a replacement remote joystick 
because the one that you were sent was defective. The Plan denied your request. The Plan says the shroud is 
ideal for outdoor use and not medically necessary in the home. The Plan also says this item still does not meet 
the coverage criteria. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a shroud model (K0108).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee (L5828, L5845, L5848, L5856) for a lower 
limb prosthesis.  

You asked the Plan to pre-approve microprocessor knee. You say that these components are needed to 
participate in daily routines and activities. The Plan denied your request. The Plan says that the computerized 
knee exceeds the enrollee's medical needs. 
 
The Plan follows Medicare rules. Medicare rules state that determination of the medical necessity of lower limb 
prosthetic components is based on assessment of the enrollee's functional level. 
 
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 microprocessor knee. Our reviewer says 
that the enrollee does not meet criteria for the requested components. Our physician reviewer found the medical 
record go above and beyond in satisfying Medicare policy by demonstrating this enrollee has K3 functional 
level potential and has specific needs for the requested components. For this enrollee or any comparable K3 
ambulator, lesser devices simply would not meet functional needs and would amount to substandard 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 microprocessor knee have been met. Therefore, we decided that the Plan has to 
pre-approve a microprocessor knee (L5828, L5845, L5848, L5856) for a lower limb prosthesis.  
 
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 pay for procedure codes 87481-XU, 87653-XU, and 87798-XU 
billed for date of service January 19, 2023. 
 
You asked the Plan to pay for codes 87481, 87653, and 87798. You say that these services were billed 
correctly. The Plan denied your request. The Plan says these services are 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 CPT code. 
 
In this case, we have confirmed that codes 87481, 87653, and 87798 are column II codes to column I code 
87801; however, codes 87481, 87653, and 87798 were billed with a modifier.  
 
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 codes 87481, 87653 and 87798. Our reviewer says that the 
records do not support that these codes are separately payable. Our reviewer found these codes were billed with 
modifier XU, indicating unusual non-overlapping services, to bypass the NCCI Edit with 87801, but the 
laboratory report does not include documentation to support these were unusual non-overlapping services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87481, 87653 and 87798 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 87481-XU, 87653-XU, and 87798-XU billed for date of 
service January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service March 9, 
2023.  
 
You asked the Plan to pay for procedure code 87640. You say that these services are supported as billed. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87640 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87640 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87640 billed for date of service March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code L5781. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code L5781 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code L5781.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories (E0955, E1002, E1012, E1028, E2311, E2361, E2607, E2620, K0856).  

You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. 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 power mobility devices are covered when specific 
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 group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. 
 
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 group 3 power wheelchair with single power option and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
single power option and accessories (E0955, E1002, E1012, E1028, E2311, E2361, E2607, E2620, K0856).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 25290-AS-LT billed for date of service April 24, 2023. 
 
You asked the Plan to pay for code 25290-AS-LT. You say that the approval for these services should be 
included in the approval for the surgery itself. The Plan denied your request. The Plan says surgical assistant 
services are not paid for code 25290. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 25290-AS-LT. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not 
medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria 
for code 25290-AS-LT have not been met. Therefore, we decided that the Plan does not have to pay for code 
25290-AS-LT billed for date of service April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377) and 
adjustable detachable armrests (E0937).  
 
You asked the Plan to pre-approve upgraded electronics and adjustable detachable armrests . You say that the 
enrollee currently has pressure sores. You say that the enrollee cannot independently perform weight shifts for 
pressure relief. You also say that this is medically necessary for the enrollee.  The Plan denied your request. 
The Plan says the notes do not show a medical need to control the power options through the joystick. The Plan 
also says that the adjustable armrests are included in the already approved power tilt and recline.  
 
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 upgraded electronics and adjustable 
detachable armrests. Our reviewer says that the items which remain in dispute are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has paraplegia. The enrollee's 
upper extremity strength is 4/5 bilaterally and she is able to manage her cecostomy and neurogenic bladder 
independently. The enrollee does not require an alternative means of managing power drive. The armrests are 
included with the power and tilt recline chair that was already approved by the Plan.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics and adjustable detachable armrests have not been met. 
Therefore, we decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377) 
and adjustable detachable armrests (E0937).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 13, 2022, billed with the 
following codes: 87498, 87502, 87634, U0003, U0005, and 87798.  
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and should be 
paid in full. The Plan denied your request. The Plan says you should have submitted these lab services as a 
single panel code (87633) instead of individual codes. 
 
The Plan follows Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single code shall be reported for the procedure. If there is no code that describes 
the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of 
service. 
 
In this case, instead of billing a single code with a single unit of service, you billed a list of codes for one 
multigene panel.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on October 13, 2022, billed with the following codes: 87498, 87502, 87634, U0003, U0005, 
and 87798.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 home health skilled nursing visits (G0299).  
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the requested 
services are not reasonable in the amount and duration as, until there is adequate soft tissue coverage of the 
wound, the wound would not be expected to heal. The enrollee is receiving a palliative wound care regimen 
which is not complex and has demonstrated an ability to perform. The review has determined that the records 
did not show that skilled nursing services are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the 
enrollee's condition and/or prevent deterioration. The records did not show that skilled therapy services are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 home health skilled nursing visits (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documented trial and failure 
of a brace for fracture treatment for this enrollee. More conservative measures are needed prior to surgery. The 
criteria for coverage are not met and the services are not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition supplies billed for dates of service 
February 16, 2023, to February 21, 2023, with the following codes: B4224, B4220, and B4193 
 
You asked the Plan to pay for the parenteral nutrition supplies. You say that you have provided medical records 
to support payment. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for these specific codes. While there is a physician order in 
the medical records, it is not specific with regard to the specific items being ordered for the patient and it does 
not provide any codes for the items being ordered. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for parenteral nutrition supplies billed for dates of service February 16, 2023, to February 21, 2023, with the 
following codes: B4224, B4220, and B4193