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

 
We decided that the Plan does not have to pre-approve 8 additional routine transportation rides. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation because you have no way of getting to your physical therapy and doctors' appointments.  The 
Plan denied your request. The Plan says you are only entitled to 24 rides per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided the 
Plan cannot be obligated to provide you with transportation in excess of what is listed in your Evidence of 
Coverage. Therefore, we decided that the Plan does not have to pre-approve 8 additional routine transportation 
rides.
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. The Plan denied your request. The Plan says once the 
enrollee completes hospital care there is no need for daily physician visits nor specialty nursing care. Services 
needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Mastergraft allograft (20930). 
 
You asked the Plan to pre-approve Medtronic Mastergraft allograft. 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 Medtronic Mastergraft allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Mastergraft allograft is experimental in the posterior spine. Iliac crest autograft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Medtronic Mastergraft allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Medtronic Mastergraft allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87481-XU and 87653-XU billed on November 14, 
2022. 
 
You asked the Plan to pay for codes 87481-XU and 87653-XU. You say that this was billed correctly. The Plan 
denied your request. The Plan says this is not supported in the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say modifier XU indicates 
Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual 
components of the main service. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique, and  the definition of 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. 
 
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-XU and 87653-XU. Our reviewer says that 
these codes are not supported. Our reviewer found the submitted laboratory report does not include 
documentation to support these procedures are 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-XU and 87653-XU have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 87481-XU and 87653-XU billed on November 14, 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's medical condition and needing further 
assistance. The Plan denied your request. The Plan says intensive rehabilitation service is not medically 
reasonable or 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service January 21, 
2022. 
 You asked the Plan to pay for procedure code 99213. You say that you added a modifier to the claim, but it still 
denied. The Plan denied your request. The Plan says payment for code 99213 is bundled into payment for code 
95004. 
 
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 99213 
is a column II code to column I code 95004. This claim has not been billed with an appropriate modifier to 
bypass the edit. Although you stated that you added a modifier to the claim, there is no evidence of a modifier 
being appended to code 99213. If you wish to do so, you will need to contact the Plan directly. 
 
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 99213 billed for date of service January 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 18, 2022 to 
November 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. 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 October 18, 2022 to 
November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial dentures. 
 
You asked the Plan to pre-approve partial dentures. You say that you fell and broke your dentures, so you need 
new ones. The Plan denied your request because your benefit for dentures has already been exhausted. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Your Plan only covers 
dentures once every 60 months. The record shows you exhausted your denture benefit on June 8, 2021. 
Therefore, we decided that the Plan does not have to pre-approve partial dentures.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83655, 83785, 83825, 83885, 84255, 
84630, 82108, 82175, 82300, 82495 and 82525) provided on December 28, 2022. 
 
You asked the Plan to pay for the laboratory services . You say that you are appealing the Plan's rejection of the 
$305 lab fee.  The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory services. 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 documentation that the heavy metal testing at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for you. The provided records in this case do not 
document a detailed medical history, including a careful documentation of occupational and avocational 
exposure to these toxins and records do not document a complete physical examination of the patient, as 
required by the LCD L35074.  
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (83655, 83785, 83825, 83885, 84255, 84630, 82108, 82175, 
82300, 82495 and 82525) provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lightweight wheelchair purchased on November 21, 
2022. 
 
You asked the Plan to pay for the lightweight wheelchair. You say that this wheelchair was purchased so that 
your mother could go to the park and other outings.  You said that regular wheelchairs are too heavy to fold 
and put into the car. The Plan denied your request. The Plan says medical equipment for use outside the home 
is not covered. 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 pay for the lightweight wheelchair purchased on 
November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87481, 87640, 87652, 87799 and 87900 billed on 
January 4, 2023. 
 
You asked the Plan to pay for codes 87481, 87640, 87652, 87799 and 87900. You say that this was billed 
correctly. The Plan denied your request. The Plan says these codes 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 87481 is candida species, amplified probe technique. The 
definition of 87640 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique. The definition of 87652 is streptococcus, group A, quantification. The definition of 
87799 is infectious agent detection by nucleic acid (DNA or RNA) not otherwise specified; quantification, each 
organism. The definition of 87900 is infectious agent drug susceptibility phenotype prediction using regularly 
udated genotypic bioinformatics. 
 
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, 87640, 87652, 87799 and 87900. Our reviewer 
says that these codes are not supported. Our reviewer found these procedures were not found in the laboratory 
report and therefore cannot be verified as performed. 
 
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, 87640, 87652, 87799 and 87900 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 87481, 87640, 87652, 87799 and 87900 billed on January 
4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring from 
outside the operating room or for monitoring of more than one case while in the operating room represented by 
code 95941 for date of service June 25, 2022. 
 
You asked the Plan to pay for code 95941. You say that the operating surgeon requested intraoperative 
neuromonitoring out of medical necessity. You say that the enrollee did not have a choice to pick an in-network 
provider. You say that the enrollee was unconscious when the decision was made.  The Plan denied your 
request. The Plan says the code in dispute is not payable by Medicare.   

The Plan must follow Medicare rules. Medicare rules say that code 95941 is not payable by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 95941 have not been met. Therefore, we decided that the Plan does not have to pay for 
continuous intraoperative neurophysiology monitoring from outside the operating room or for monitoring of 
more than one case while in the operating room represented by code 95941 for date of service June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you have provided medical 
records to support coverage of this item. The Plan denied your request. The Plan says the patient does not meet 
criteria for an oxygen concentrator. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
In this case, the patient's medical records indicate that their oxygen saturation rate is 95%.  The patient's 
oxygen saturation rate is too high to qualify for oxygen equipment in accordance with the Medicare rules 
above. Based on this information, we decided that Medicare rules for coverage of a portable oxygen 
concentrator have not been met.  Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 
You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documented trial of bracing. 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the implantable CardioMEMS device is still an investigational device and not 
recommended by any professional societies/association as a part of Heart Failure treatment 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
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 the requirements. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient requires home ventilation and 
other therapies have been considered and ruled out due to the severity of the patient's disease state. The Plan 
denied your request. The Plan says continued use of a home ventilator is not medically necessary. This device 
is being used solely in an average volume-assured pressure support (AVAPS) mode, and this could be 
accommodated with a bilevel positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that continued used of a home ventilator is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that the enrollee has been treated with AVAPS mode ventilation.  The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure of such a 
device has not been documented.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a home ventilator.