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

 
We decided that the Plan does not have to pay for inpatient care provided on December 20, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the inpatient hospital services are not supported in the record. Specifically, the claim was not 
submitted with a valid type of bill. Type of bill 110 is for non-payment. Based on this information, we decided 
that Medicare rules for coverage of the inpatient care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient care provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty procedure (22513). 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical record clearly documents that this enrollee does not meet evidence-based 
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 pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. The enrollee is not hospitalized with severe pain or noted to be in severe pain with a clearly 
documented pain rated at 5 or greater on NRS or VAS. Additionally, there is no documentation of progression 
of the vertebral body height loss and the MRI noted only 20% loss of vertebral body height. The magnetic 
resonance imaging (MRI) also demonstrated mild posterior displacement of the posterosuperior cortex with 
near ventral cord abutment (without cord compression). There is retropulsion of the fracture. Overall, there is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T12 kyphoplasty procedure (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system and multiaxial ankle with swing 
phase active dorsiflexion feature. 
 
You asked the Plan to pre-approve a flex-walk system and multiaxial ankle with swing phase active 
dorsiflexion feature. You say that the services are necessary. The Plan denied your request. The Plan says 
based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) 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 flex-walk system and multiaxial ankle 
with swing phase active dorsiflexion feature. Our reviewer says that the services are not medically necessary. 
Our physician reviewer found a flex-walk system and multiaxial ankle with swing phase active dorsiflexion 
feature exceeds your functional needs per the Lower Limb Prosthesis LCD. The documentation does not 
include physician office visit notes since you had lumbar surgery that you are a K3 level ambulator. The last 
physician progress notes states you are to have back surgery in November 2022 and will need a wheelchair 
potentially for over 6 months. There are no updated physician office visit notes corroborating the vendor's notes 
that you are a K3 ambulator. 
 
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 flex-walk system and multiaxial ankle with swing phase active dorsiflexion 
feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a flex-walk system 
and multiaxial ankle with swing phase active dorsiflexion feature.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were submitted. The Plan 
denied your request. The Plan says the code cannot be separately reimbursed. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
 
 We find that CPT code 99292 is not supported. Specifically, this add-on code was not billed with a primary 
procedure code on the date of service at issue. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99292 billed for date of service July 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization services billed with code 37221 for date 
of service November 17, 2022. 
 
You asked the Plan to pay for the revascularization services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as 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 37221 is revascularization, endovascular, open or 
percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty 
within the same vessel, when performed. 
 
 
 We find that CPT code 37221 is not supported in the medical record. Specifically, this service was not billed 
with an anatomical modifier. Without this required modifier, this code is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the revascularization services have not been met. 
Therefore, we decided that the Plan does not have to pay for the revascularization services billed with code 
37221 for date of service November 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you feel that home health care is 
necessary for you. 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 based on the 
limited and retrospective documentation provided, the criteria for home health care are not met.  The enrollee 
does not currently have documented skilled nursing needs. The enrollee does not currently have documented 
skilled therapy needs. As such, the requested services are not shown to be currently medically necessary or 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 17, 2022, billed with 
code 71271. 
 
You asked the Plan to pay for the imaging services provided.. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 The Plan must follow Medicare rules. Medicare rules say that claims for low-dose CT lung cancer screenings 
are denied if they are not reported with the listed diagnosis codes.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with diagnosis codes 
Z12.2 and J43.9 which are not listed diagnosis codes for this procedure. Therefore, we decided that the Plan 
does not have to pay for imaging services provided on August 17, 2022, billed with code 71271.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing provided on July 19, 2022. 
 
You asked the Plan to pay for the PrismRA testing. You say that the service was necessary for the enrollee. The 
Plan denied your request. The Plan says the testing was 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 pay for the PrismRA testing. Our reviewer says that 
the PrismRA testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is an unmet clinical need for a test that can accurately predict which patients will or will not respond to targeted and biologic therapies. Therefore, the reviewer found that the PrismRA testing 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 the PrismRA testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the PrismRA testing provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for scanning computerized ophthalmic diagnostic imaging, posterior 
segment, with interpretation and report, unilateral or bilateral; optic nerve received on July 13, 2022. 
 
You asked the Plan to pay for the services. You say that the provider made an error. The Plan denied your 
request. The Plan says that this is not covered under any normal circumstances. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
The Evidence of Coverage doesn't directly exclude coverage for the exam at issue n this case. There was no 
notice given that this service would not be covered. We looked at the file and the Plan's rules. Based on this 
information, we decided that the Plan's rules for coverage of the services have been met. Therefore, we decided 
that the Plan has to pay for scanning computerized ophthalmic diagnostic imaging, posterior segment, with 
interpretation and report, unilateral or bilateral; optic nerve received on July 13, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120), bone 
replacement graft for ridge preservation (D7953), and surgical removal of erupted tooth (code D7210). 
 
You asked the Plan to pre-approve fixed partial denture sectioning, bone replacement graft for ridge 
preservation, and surgical removal of erupted tooth. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fixed 
partial denture sectioning (D9120), bone replacement graft for ridge preservation (D7953), and surgical 
removal of erupted tooth (code D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent observation care services coded 99226 for 
date of service 
 
You asked the Plan to pay for the subsequent observation care services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed 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 99226 is subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99226 is not supported in the medical record. Specifically, this service was billed with a 
place of service 22 (outpatient). The documentation shows that the enrollee was inpatient from July 19, 2022, 
to July 25, 2022. This means the incorrect place of service was billed with this claim. The claim is not payable 
as billed. Based on this information, we decided that Medicare rules for coverage of the subsequent observation 
care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
observation care services coded 99226 for date of service
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing provided on September 20, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was not 
billed with the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the claim was not billed with the appropriate DEX Z-code. 
However, the Plan has not provided documentation showing that the billed DEX Z-code, Z00D5, is not 
appropriate in this case. Without supporting documentation, the Plan's denial has not been substantiated. 
Therefore, we decided that the Plan has to pay for the testing provided on September 20, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to services provided on October 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for to services provided on October 14, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prosthetic implant (L8699) provided on August 30, 2022. 
 
You asked the Plan to pay for the implant. You say that this should be paid for. The Plan denied your request. 
The Plan says more details are needed to determine if the charges are eligible for coverage. 
 
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 implant. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation is insufficient to support that the prosthetic implant (L8699) provided on 8/30/2022 was medically reasonable and necessary for the enrollee in this case. The clinical documentation is 
limited to a clinic operative report. 
 
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 implant have not been met. Therefore, we decided that the Plan does not 
have to pay for a prosthetic implant (L8699) provided on August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitrectomy chair received on July 28, 2022. 
 
You asked the Plan to pay for the vitrectomy chair. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the item received is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the vitrectomy chair received on July 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan to be provided by a 
tertiary level of care provider. 
 You asked the Plan to pre-approve CT scan. You say that your doctor was not satisfied with the previous 
imaging results so wants this imaging to be done by the tertiary level provider. The Plan denied your request. 
The Plan says it is not medically necessary to have this CT scan done by the tertiary-level provider and your 
needs can be met by another provider instead. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs.  
 
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 CT scan. Our reviewer says that you do 
not meet criteria to have this CT scan at the requested tertiary level of care provider. Our physician reviewer 
found the Plan is offering adequate care to meet your needs at the community (non-tertiary) level of care. There 
is not anything unique about your condition that would make it medically necessary to have this CT scan 
performed by the requested tertiary level provider. The Plan has community-level providers who meet the 
standards of care required for treatment of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan to be provided by a tertiary level of care provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro powered arm brace. 
 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this 
enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro powered arm brace.