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

 
We decided that the Plan does not have to pay for the definitive drug testing provided on October 13, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this is 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 drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records sent by the provider shows presumptive screening test results which are partially inconsistent with prescription medications, or history and expected results. Definitive confirmation testing was 
medically necessary for only one drug class. The requested definitive drug testing at issue in this case was 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on October 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (J7999) provided on July 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 J7999 is "Compounded drug, not otherwise classified". 
 
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 J7999 is 
not supported by the records provided. Our reviewer found that the procedure report does not include 
documentation of a compound drug given. The documentation supports a fentanyl injection. There is a more 
appropriate code to report for the documented service.  
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 services (J7999) provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, 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 been no documentation of a failure of a four week trial of conservative 
therapy. 
 
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 Medicare requires a trial of conservative treatment prior to the use of this device. There is no 
evidence of this in the records. 
 
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 (E0651, E0667.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pre-approval for home health physical therapy services 
(G0151), home health skilled nursing services (G0299), and home health aide services (G0156). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says you are not home bound, and the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 pre-approval for home health physical 
therapy services (G0151), home health skilled nursing services (G0299), and home health aide services 
(G0156). Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found that you are not shown to be homebound. You do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs.  
 
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 pre-approval for home health physical therapy services (G0151), home health 
skilled nursing services (G0299), and home health aide services (G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is expected to make measurable 
functional gains as well as improve medical status within a reasonable time of admission to the inpatient 
rehabilitation program. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (Silverado Extreme scooter) 
(K0812). 
 
You asked the Plan to pre-approve a Silverado Extreme scooter. The Plan denied your request. The Plan says 
you were recently approved a group 2 powered operated vehicle on April 11, 2023. The Plan also says that the 
notes do not show that a "Silverado Extreme scooter" powered operated vehicle is appropriate. 
 
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 Silverado Extreme scooter. Our 
reviewer says that this request is not medically reasonable and necessary. Our physician reviewer found you 
have been authorized to have a group 2 power wheelchair through a specialty evaluation. Our reviewer also 
found that the requested powered scooter for community use is not 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 Silverado Extreme scooter have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle (Silverado Extreme scooter) (K0812).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway 
collapsibility (E0486). 
 
You asked the Plan to pre-approve an oral device/appliance. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for an oral appliance because the Apnea Hypopnea Index (AHI) on their sleep 
study was not high enough. 
 
The Plan follows Medicare rules. Medicare rules say that a custom fabricated mandibular advancement oral 
appliance (E0486) used to treat obstructive sleep apnea (OSA) is covered if the criteria listed in the Medicare 
rules section of this letter are met. 
 
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 an oral device/appliance. Our reviewer 
says that the enrollee does not meet the LCD coverage criteria for the requested oral device/appliance (E0486). 
Specifically, the enrollee has not trialed a standard continuous positive airway pressure (CPAP). Our reviewer 
also found that claustrophobia is not a condition that an oral device vendor or a dentist is qualified to diagnose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oral device/appliance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oral device/appliance used to reduce upper airway collapsibility (E0486).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it would not be clinically advantageous at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from 
October 15, 2021, to October 31, 2021. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the records do not support a 
physical therapy/occupational therapy (PT/OT) function score of 10-23. 
 
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 skilled nursing facility (SNF) services rendered from October 15, 2021, to October 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77523). 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. 
 
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 proton beam therapy. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found treatment guidelines do not consider 
proton therapy for prostate cancer to be experimental; however, any potential benefit or detriment of proton 
therapy over standard intensity-modulated radiation therapy (IMRT) is an investigational question being pursue 
by clinical trials. IMRT with or without image-guide radiation therapy (IGRT) are also highly effective and 
well tolerated. To date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton 
beam therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77523).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service January 
18, 2023. 
 You asked the Plan to pay for procedure code(s) 88305. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this code is included in the facility payment and 
is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service January 18, 
2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Vacuum Assisted Socket System (VASS) (L5781) and an 
alignable system (L5910). 
 
You asked the Plan to pre-approve a VASS and alignable system. The Plan denied your request. The Plan says 
that experimental and investigational items are not covered by Medicare. The Plan also says a replacement 
alignable system exceeds the enrollee's need and is not reasonable and necessary for the approved replacement 
socket. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 VASS and alignable system. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the Certified Prosthetist's/Orthotist's very thorough appeal letter offers up a 
relevant literature review supporting the efficacy of VASS, a factual discussion of the modern standard of 
prosthetic care which does include VASS, and cites to comparable Administrative Law Judge (ALJ) rulings in 
favor of this technology, which definitively disproves the Plans assertion that Medicare considers VASS 
experimental. Our reviewer found that an alignable system is not usually recycled between sockets precisely 
because it is laminated directly into the structure of the previous socket. Our physician reviewer found that 
therefore, the VASS (L5781) and alignable system (L5910) are approved. 
 
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 VASS and alignable system have been met. Therefore, we decided that the 
Plan has to pre-approve a Vacuum Assisted Socket System (VASS) (L5781) and an alignable system (L5910).  
 
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 procedure code 87652 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 87652. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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 87652 is: Infectious agent detection by nucleic acid 
(DNA or RNA); Streptococcus, group A, quantification. 
 
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 procedure code 87652. Our reviewer says that procedure 
code 87652 does not meet criteria for payment. Our reviewer found that the laboratory report documents testing for group A streptococcus; however, a separate report is not documented, and therefore the procedure code 
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 procedure code 87652 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87652 billed for date of service October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from October 5, 2021, to October 13, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on March 17, 2022, and April 5, 2022. Comparison of the claims shows these are exact duplicates. 
There is no evidence presented to support that the billed services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services provided from October 5, 2021, to October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without fusion.  
 
You asked the Plan to pre-approve the procedure. You say that this treatment plan is medically necessary and 
appropriate. The Plan denied your request. The Plan says this service is not covered under Medicare as it is not 
considered to be reasonable and 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 pre-approve the procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Coflex device is experimental, and more research is 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without 
fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from October 27, 2022, to October 29, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not 
support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
submitted documentation does not contain medical records for the dates of service in question. Therefore, we 
decided that the Plan does not have to pay for the services provided from October 27, 2022, to October 29, 
2022.