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

 
We decided that the Plan does not have to pre-approve the Sprint PNS system (64555). 
 
You asked the Plan to pre-approve the Sprint PNS system. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of Sprint PNS System in the 
setting of chronic shoulder pain secondary to terminal stage degenerative joint disease has not been 
demonstrated in the peer-reviewed literature.  
 
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 Sprint PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Sprint PNS system is experimental for chronic shoulder 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 the Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Sprint PNS system (64555).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
August 31, 2023, to September 02, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for inpatient hospital care. 
 
You have been asked to pay a $175 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $350 for the inpatient hospital stay ($175 copayment 
x 2 days = $350). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on August 31, 2023, to 
September 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote interrogation device provided on July 24, 2023. 
 
You asked the Plan to pay for the remote interrogation device. You say that you are requesting reconsideration 
of the denied claim. 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 remote interrogation 
device provided on July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and bilateral 
leg sleeves (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that the medical 
records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says 
under Medicare's guidelines, a pneumatic compression device is not reasonable or necessary.  
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
sleeves. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, there is no documentation of a failed trial as 
the enrollee has not used an adequate compression garment with a minimum of 30 mmHg. In addition, there 
has been a slight decrease in the enrollees edema with the use of tubi grip (10-15 mmHg) compression. The 
review has determined that the medical records provided do not. show that the enrollee has met the medically 
necessary requirements listed in the LCD for Medicare coverage 
 
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 pneumatic compression device and sleeves have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and bilateral leg 
sleeves (E0667).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services rendered from April 6, 2023, to 
April 21, 2023. 
 
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 FDPC1 is not supported by the therapy notes.. 
 
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. We find that The plan has said that the clinical documentation does not support 
the Non-Therapy Ancillary (NTA) score. However, the plan has not specified or provided any information in 
their submission as to what the NTA score actually was. A review of their denial cannot be done. Therefore, we 
decided that the Plan has to pay for skilled nursing facility (SNF) services rendered from April 6, 2023, to April 
21, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services described by code 82947 and the 
injection services described by code S0073 billed for date of service January 16, 2023. 
 
You asked the Plan to pay for 82947 and S0073. You say that 82947 and S0073 should be paid as billed 
because they are supported in the documentation and were coded correctly. The Plan denied your request. The 
Plan says 82947 is denied because this code is not paid under OPPS. S0073 is denied because it is not valid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that services with an OPPS payment status indicator 
of A are not paid under OPPS. The rules also say that codes assigned a Physician Fee Schedule status indicator 
of I are not valid for Medicare purposes. 
 
We looked at the file and Medicare rules. We confirmed that the claim was billed in the outpatient hospital 
setting. We confirmed that 82947 has an OPPS payment status indicator of A, meaning there is no payment for 
this code under OPPS. We also found that procedure code S0073 has a status indicator of I on the Physician 
Fee Schedule. This means that procedure code S0073 is not valid for Medicare purposes on any type of claim. 
Based on this information, we decided that Medicare rules for coverage of 82947 and S0073 have not been 
met. Therefore, we decided that the Plan does not have to pay for the laboratory services described by code 
82947 and the injection services described by code S0073 billed for date of service January 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques, requiring use of operating 
microscope (69990). 
 
You asked the Plan to pre-approve an operating microscope. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the National Correct Coding Initiative (NCCI) program bundles CPT 
code 69990 into all surgical procedures, other than those listed in the Medicare Claims Processing 
Manual. 
 
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 CPT code 69990 cannot be billed for separately in this type of surgery. Specifically, code 69990 is 
bundled into all surgical procedures except those listed in the Medicare Claims Processing Manual. Based on 
this information, we decided that Medicare rules for coverage of an operating microscope have not been met. 
Therefore, we decided that the Plan does not have to pre-approve microsurgical techniques, requiring use of 
operating microscope (69990).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87481, 87551, 87561, and 87641 provided on March 
17, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87551, 87561, and 87641. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services 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 Infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87551 is Infectious agent 
detection by nucleic acid (DNA or RNA); Mycobacteria species, amplified probe technique. The definition of 
code 87561 is Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, 
amplified probe technique. The definition of code 87641 is Infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. 
 
We find that CPT codes 87481, 87551, 87561, and 87641 are supported in the medical record. Specifically, the 
records show that these tests were ordered, and the results were provided. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 87481, 87551, 87561, and 87641 have been met. 
Therefore, we decided that the Plan has to pay for procedure codes 87481, 87551, 87561, and 87641 provided 
on March 17, 2023.  
 
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 infectious agent detection by nucleic acid (DNA OR RNA); 
chlamydia trachomatis, amplified probe technique (87491) and infectious agent detection by nucleic acid 
(DNA OR RNA); staphylococcus aureus, amplified probe technique (87640) provided August 7, 2023.  
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the medical records submitted 
does not include a physician order or laboratory requisition for 87491. 87640-59 is included in CPT code 
87641; this means, it 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 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique and 87640 is infectious agent detection by nucleic 
acid (DNA or RNA); Staphylococcus aureus, 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 the laboratory services. Our reviewer says that the billed 
service is not supported in the medical records. Our reviewer found them medical record includes a physician 
order and laboratory report, however billed test for CPT 87491 was not included on either document, and 
therefore cannot be verified. The provider reported procedure code 87640 with appended modifier 59 distinct 
procedural service to bypass NCCI Edit with CPT 87641 Staphylococcus aureus, methicillin resistant.  
However, laboratory report does not include documentation to support a distinct procedural service, therefore 
this procedure would be inclusive to more comprehensive procedure, CPT 87641. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for infectious agent detection by nucleic acid (DNA OR RNA); chlamydia trachomatis, 
amplified probe technique (87491) and infectious agent detection by nucleic acid (DNA OR RNA); 
staphylococcus aureus, amplified probe technique (87640) provided August 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Percutaneous Vertebroplasty (22510) provided on June 12, 
2023. 
 
You asked the Plan to pay for Percutaneous Vertebroplasty. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the code billed 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 22510 is Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic. 
 
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 Percutaneous Vertebroplasty. Our reviewer says that the 
records do not support the billed service. Our reviewer found no operative report was found to support billing CPT 22510, therefore this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Percutaneous Vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pay for Percutaneous Vertebroplasty (22510) provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 22, 2023, billed with 
procedure code 99213-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99213-25 is office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the procedure report describes 
assessment of wound in addition to wound care, a significant, separately identifiable evaluation and 
management service was not included in the documentation.   
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 22, 2023, billed with procedure code 
99213-25.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PAE.

You asked the Plan to pre-approve PAE. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the requested PAE is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that therapeutic embolization is covered when done for hemorrhage, and for other conditions amenable to treatment by the procedure, when reasonable and necessary for the individual patient.

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 PAE. Our reviewer says that this procedure is not medically necessary. Our physician reviewer found the records do not show that you have an
intractable prostatic hemorrhage as required. The records show that you have symptomatic benign prostatic hyperplasia (BPH), which is not covered. Prostatic arterial embolization is considered an experimental technique to treat symptomatic BPH. Very limited studies have demonstrated possible short-term safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PAE have not been met. Therefore, we decided that the Plan does not have to pre-approve PAE.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (E1230). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that the requested vehicle is a necessity 
for your care. The Plan denied your request. The Plan says rules for coverage for PMDs have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs, that your 
condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power operated vehicle (E1230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve a microprocessor ankle foot system. You say that you are still active and 
involved with your construction/excavating business. There is no doubt that the electronic foot would help you 
greatly in being more mobile and much safer.  The Plan denied your request. The Plan says a replacement K3 
foot exceeds the enrollee's needs and is not medically necessary. Medicare does not cover replacement for 
items under manufacturer's warranty. 
 
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 microprocessor ankle foot system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found a microprocessor ankle foot system is not the standard of care. The 
response and efficacy of the system varies widely across individuals. The system is not predictably effective 
and has significant disadvantages, including need for greater clearance under the socket, weight and 
maintenance. There is no evidence the requested system is medically necessary and will accomplish the 
enrollee's goals.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a microprocessor ankle foot system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-controlled 
feature, dorsiflexion and/or plantar flexion control, includes power source (L5973).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, E656). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0667, E656).