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

 
We decided that the Plan does not have to pay for two units of procedure code 87481 rendered on July 7, 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 the laboratory report does not show the individual candida species were separately tested on the 
billed date of service. 
 
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."  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee has a history of 
prostate issues since prostate cryoablation, including frequent urinary tract infection. Urine samples were 
collected, and two units or procedure code 87481 were rendered. However, the provided lab report does not 
clearly show that the individual candida species were separately tested on the above date to justify the reported 
units. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 87481 rendered on July 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 rendered on June 26, 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 Current Procedural Terminology (CPT) code 99223-AI (1 Unit) remains not supported.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical decision making is 
not of high complexity.  The amount of time spent caring for the patient is not noted  As such, the billing of 
CPT 99223 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99233 rendered on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that the enrollee needs a powered scooter because their 
last chair was stolen. The Plan denied your request. The Plan says the requested scooter is not medically 
necessary under Medicare. 
 
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.  
 
 
 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 scooter. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has chronic back pain and is 
requesting the device to assist community mobility. Per NCD 280.3, the device is not necessary to assist in 
home self-care 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 a scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle (K0800).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Renflexis injection (Q5104). 
 You asked the Plan to pre-approve a Renflexis injection. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Renflexis injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed 
the required drugs. There is no documentation provided indicating that the plan's required drugs would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
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 Renflexis injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Renflexis injection (Q5104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that despite the enrollee being treated 
with gold standard therapies, the enrollee remains symptomatic daily and was recently hospitalized for critical 
carbon dioxide retention. You say that the enrollee was treated with a BiPAP while in the hospital but remained 
critically hypercarbic. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary for this patient because their needs can be met with an alternative device such as a BiPAP device 
with average volume-assured pressure support (AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
was treated and responded appropriately with BiPAP therapy. There was no escalation or failure of therapy 
during the documented hospitalization. Also, there is no documentation to support escalation for therapy. 
Therefore, the enrollee can continue with BiPAP therapy with AVAPS if 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says that the needed settings 
could be equally provided by a BiPAP with average volume-assured pressure support (AVAPS). 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 the service is not medically necessary. Our physician reviewer found the enrollee presented with severe 
COPD exacerbation from pneumonia and required mechanical ventilatory support. The enrollee had previously 
required a home ventilator and was not compliant. The documentation and data provided supports the need and 
benefit from a home ventilator. Hence, per best practice, the home ventilator is indicated and 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 a home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation device. 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 high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries 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 a high frequency chest wall oscillation 
device. Our reviewer says that the services are not medically necessary. Our physician reviewer found given 
documentation and data provided, the enrollee does not meet criteria or indication for high frequency chest wall 
oscillation devices (HFCWO). Hence, no High frequency chest wall oscillation devices (HFCWO) is indicated. 
 
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 high frequency chest wall oscillation device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (E0483).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zoryve cream. 
 
You asked the Plan to pre-approve the medication. You say that this medication is medically necessary and 
appropriate. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zoryve cream.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation (PNS) using a Sprint 
device (64555, C1778, L8680). 
 
You asked the Plan to pre-approve a Sprint PNS system. You say that the denial for this procedure is 
unwarranted and unsupported. The Plan denied your request. The Plan says percutaneous PNS is unproven and 
not medically necessary due to insufficient evidence of efficacy. 
 
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 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 the enrollee has chronic low back pain. Her pain medications included Hydrocodone, 
Oxycodone, Morphine, and Tramadol. She has had chiropractic care and physical therapy. She has had epidural 
steroid injections. This is considered experimental therapy. It is the subject of ongoing clinical trials. Therefore, 
the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve peripheral nerve stimulation (PNS) using a Sprint device (64555, C1778, L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (64635). 
 
You asked the Plan to pre-approve lumbar radiofrequency ablation. You say that you are requesting 
reconsideration and have submitted medical records for review. The Plan denied your request. The Plan says 
the request is not medically necessary and not a covered benefit. 
 
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 lumbar radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic low back and failed back surgery syndrome. On 
October 4, 2023, the enrollee had a diagnostic medial branch block at right L4-L5 which gave him 70% pain 
relief. He then a had a repeat diagnostic block at that level which gave him 95% pain relief. The LCD criteria is 
80% pain relief from both diagnostic blocks. Since the first one only gave him 70% pain relief, the request is 
deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar radiofrequency ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lumbar radiofrequency ablation (64635).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart for 
calcium scoring. 
 
You asked the Plan to pre-approve the CT scan. 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 the enrollee must meet at least one of the medical 
indications listed in the LCD under the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the record indicates that the enrollee does not 
have signs or symptoms of cardiac disease or hypercholesterolemia and has a history of normal stress test. The 
record provided does not establish the presence of a condition for which coverage is available for the requested 
service. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart for calcium scoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0841) and accessories 
(E0955, E1007, E1012, E1028, E2311, E2313, E2359, E2377, E2622). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that your current chair is 
damaged, the batteries no longer charge and the tires on the power wheelchair are broken. You also say the 
chair can only go 100 yards and will stop. The Plan denied your request. The Plan says you do not have a 
qualifying diagnosis causing mobility limitation for which a group 3 power wheelchair is medically needed. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have impaired mobility and use a power wheelchair. You are able 
to stand and walk short distances. You are seeking replacement and an upgrade of your current chair. You have 
intact skin and do not use a power wheelchair. Per L33789, you do not have a high risk for skin breakdown, use 
a catheter intermittently, have spasticity or require an alternative means of managing power drive. Therefore, 
you do not meet criteria for approval of this wheelchair and accessories. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 2 standard, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0841) and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2359, E2377, E2622).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99232) 
rendered from January 10, 2023, to January 13, 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 Current Procedural Terminology (CPT) 99232 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the services provided on 
1/10/2023 appear to be an initial consultation, not subsequent care.  Therefore, the billing of CPT 99232 is not 
supported. The services provided on 1/11/2023 and 1/13/2023 were straightforward, without evidence of 
moderately complex medical decision making.  The time spent providing care to the enrollee is not 
documented. As such, the billing of CPT 99232 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99232) rendered from January 10, 2023, 
to January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller harness (E2313), expandable 
controller (E2377), sealed lead acid batteries (E2361), and elbow supports (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and 
would like the requested wheelchair and accessories approved. The Plan denied your request. The Plan says 
four batteries were requested, but only 2 batteries can be approved. The Plan also says although there are four 
requested power options (seat elevator, tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. The Plan also says that elbow supports are already included 
with the E0973 arm rest assembly, and duplicate services cannot be covered. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have paraplegia. Per Social Security Administration (SSA) 1862 (a)1(A), the 
requested accessories are not medically necessary as you have adequate strength to manage standard power 
drives. Only 2 batteries may be approved per L33792, and the elbow supports are unbundled and are a 
duplicative request per L33792. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller harness (E2313), expandable controller (E2377), sealed 
lead acid batteries (E2361), and elbow supports (K0108).