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

 
We decided that the Plan does not have to pay for the detection test by nucleic acid for Staphylococcus aureus, 
methicillin resistant (MRSA bacteria), amplified probe technique (87641) provided on January 19, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that you would not have had this test if it was not 
required. The Plan denied your request. The Plan says this test is not covered for screening purposes. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), 
amplified probe technique (87641) provided on January 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023 to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023 to January 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have stabilized medically and have been receiving skilled rehabilitation services 
in an inpatient rehabilitation facility (IRF). You have tolerated inpatient rehabilitation services and continue to 
improve with daily skilled nursing and/or skilled therapy services. You could benefit from continued services 
at the current level of care. You have made slow progress with therapy, there is no indication that transfer to a 
skilled nursing facility is required. You can continue to receive skilled rehabilitation services at the current IRF 
or be stepped down to a lower level of care when appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the need for the IRF 
admission. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity 
criteria for IRF admission. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that due to the enrollee's medical issues the 
CGM would be beneficial. The Plan denied your request. The Plan says that the enrollee does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a therapeutic CGM. Our reviewer says 
that this item is medically necessary. Our physician reviewer found although the enrollee does not use insulin 
nor has low blood glucose, the enrollee is unable to test blood glucose due to poor vision after a stroke; hence 
having the CGM will enable the enrollee to know their blood glucose levels and adjust their diet accordingly. It 
may also guide their provider towards using other medications for diabetes mellitus and blood glucose control. 
 
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 therapeutic CGM have been met. Therefore, we decided that the Plan has to 
pre-approve a therapeutic CGM.  
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 billed for December 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment may not be made by carriers for codes with a 
PC/TC indicator of 5 when they are provided to hospital inpatients or patients in a hospital outpatient 
department. 
 
We looked at the file and Medicare rules. Billed procedure code 69029 has a PC/TC indicator of 5 and was 
provided in the hospital outpatient emergency department. Payment is therefore not made for this code. Therefore, we decided that the Plan does not have to pay for procedure code 69209 billed for December 9, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for placement of soft tissue localization device(s) (eg, clip, metallic pellet, 
wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion rendered on August 17, 
2022. 
 
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 Current Procedural Terminology (CPT) code 10035-XU (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 10035 is "Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 
seeds), percutaneous, including imaging guidance; first lesion." 
 
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 supported by the medical records. Our reviewer found that the clip placement was a separate 
procedure in a separate lesion than the breast biopsy and clip placement. CPT 10035 is 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 been met. Therefore, we decided that the Plan has to pay for 
placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), 
percutaneous, including imaging guidance; first lesion rendered on August 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and lap belt 
(K0108). 
 You asked the Plan to pre-approve a power seat elevation system and lap belt. You say that the services are 
necessary. The Plan denied your request. The Plan says the requested items are not primarily medical in nature. 
 
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 pre-approve a power seat elevation system (E2300) and lap belt (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent pen. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 Dupixent pen.   
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting.  Therefore, we decided that 
the Plan does not have to pay for the lab services provided on December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of this device in the setting of chronic right upper 
extremity partial paralysis 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 device. 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 
patient's brachial plexus condition or in widespread use for this patient'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 patient. 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Myopro orthotic device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary and 
discharging home at this time is unsafe and puts the enrollee at a high risk of rebounding back to the hospital.  
The Plan denied your request. The Plan says the enrollee's needs may be met with home health services in an 
assisted living facility.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has stabilized medically and has been receiving skilled rehab services in 
an inpatient rehabilitation facility (IRF). The enrollee has tolerated inpatient rehab services and continues to 
improve with daily skilled nursing and skilled therapy services. The enrollee could benefit from continued 
services at the current level of care. The enrollee has made slow progress with therapy, there is no indication 
that transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled rehab services 
at the current IRF or be stepped down to a lower level of care when appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adolescent 
dentition (D8080). 
 
You asked the Plan to pre-approve comprehensive orthodontic treatment of the adolescent dentition. You say 
that this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
comprehensive orthodontic treatment of the adolescent dentition (D8080).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate 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 that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services at a lower level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4314 and A4357 billed for date of service 
April 7, 2022, to June 30, 2022. 
 
You asked the Plan to pay for procedure codes A4314 and A4357. You say that the items at issue have been 
billed correctly. The Plan denied your request. The Plan says procedure codes A4314 and A4357 are not 
separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A4314 and A4357 have a status indicator of P on the Physician Fee Schedule. 
This means that procedure codes A4314 and A4357 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes A4314 and A4357 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes A4314 and A4357 billed for date of service 
April 7, 2022, to June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been a four-week trial of regular, daily, multiple-hour home usage of 
E0650 and E0651. 
 
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 device. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that this device is not covered for lymphedema that is secondary to chronic venous insufficiency, absent 
venous ulcers. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 4, 2022, to 
November 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. 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 was 
not 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 4, 2022, to November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81225, 81226) provided on August 29, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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. 
 
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 use of code 81225 
and 81226 is not supported by the records provided. Our reviewer found that these procedures are included in 
another procedure that was already reported for this encounter and cannot be reported separately with the CPT 
codes in question.  
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 the lab services (81225, 81226) provided on August 29, 2022.