Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services rendered on February 7, 2023. 
 
You asked the Plan to pay for the services. You say that the diagnoses were correct. The Plan denied your 
request. The Plan says the claim was denied because it was reported with one or more diagnosis code pairs that 
are subject to an Excludes1 note. 
 
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 71045 is not supported in the medical record. Specifically, it was reported with two 
diagnosis codes - J34.9 and J44.9 - that are not allowed to be reported together. 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 radiology services rendered on February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5261) and ear mold/inserts (V5264). 
 
You asked the Plan to pre-approve hearing aids and ear molds. You say that you have an upcoming 
appointment for hearing aids and would like the service covered. The Plan denied your request. The Plan says 
the requested hearing aids and accessories are not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 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 hearing aids and ear molds have been 
met. Specifically, medical records were not submitted, and notes do now show documentation that you had a 
hearing test done. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5261) and 
ear mold/inserts (V5264).
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 you are requesting an expedited appeal to ensure the 
enrollee's safe and appropriate placement. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in 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 and/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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vagus nerve stimulation. 
 
You asked the Plan to pre-approve vagus nerve stimulation. You say that you are paralyzed on the left side and 
you want to be productive again. You say that you are in deep depression, and about to commit suicide. The 
Plan denied your request. The Plan says the requested vagus nerve stimulation does not meet the Medicare 
NCD coverage criteria. The Plan says that your medical records do not show that you have seizures or 
depression. 
 
The Plan follows Medicare rules. Medicare rules say that vagus nerve stimulation is covered when the criteria 
listed in the Medicare rules section of this decision 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 vagus nerve stimulation. Our reviewer 
says that the requested vagus nerve stimulation is not considered medically necessary in this case. Our 
physician reviewer found that you do not have a diagnosis of refractory partial onset seizures for which surgery 
is not recommended or has failed, or treatment resistant depression. While coverage for vagus nerve 
stimulation is not excluded by the Medicare NCD in the setting of neurological deficits following stroke, there 
is insufficient evidence that this intervention produces lasting meaningful clinical benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vagus nerve stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vagus nerve stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. You say that that the enrollee can benefit from the procedure 
as well as confirm their diagnosis. The Plan denied your request. The Plan says a sacroiliac joint injection 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 pre-approve the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the obtained imaging studies 
suggest other diagnosed or obvious causes of the lumbosacral pain. Therefore, the review has determined that 
the enrollee does not meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee, molded socket, shin, sach foot (L5301), a 
test socket, below knee (L5620), a below knee, acrylic socket (L5629), a below knee, total contact (L5637), a 
flexible inner socket (L5645), a below knee / above knee suspension locking mechanism (L5671), a custom 
fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with 
locking mechanism (L5673), an alignable system (L5910), ultra-light material (L5940), a microprocessor 
controlled feature (L5973), a prosthetic sheath (L8400), a prosthetic sock (L8420), a prosthetic shrinker 
(L8440) and a single ply prosthetic sock (L8470). 
 
You asked the Plan to pre-approve a new prosthetic leg and components. You say that the new prosthetics are 
medically necessary.  The Plan denied your request. The Plan says Medicare does not cover replacements for 
items under warranty.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a new prosthetic leg and components have not been met. Specifically, the enrollee received his 
prosthetics in October 2022, therefore, his current prosthetics are under warranty. A replacement can be 
supplied with the manufacturer under warranty. Therefore, we decided that the Plan does not have to pre-
approve a below knee, molded socket, shin, sach foot (L5301), a test socket, below knee (L5620), a below 
knee, acrylic socket (L5629), a below knee, total contact (L5637), a flexible inner socket (L5645), a below 
knee / above knee suspension locking mechanism (L5671), a custom fabricated from existing mold or 
prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism (L5673), an 
alignable system (L5910), ultra-light material (L5940), a microprocessor controlled feature (L5973), a 
prosthetic sheath (L8400), a prosthetic sock (L8420), a prosthetic shrinker (L8440) and a single ply prosthetic 
sock (L8470).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy rendered on February 15, 
2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says radiation cystitis is not a covered indication. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is still limited data in regard to the benefits, timing, and duration of HBO therapy in the 
treatment of radiation-induced cystitis. Due to limited available good quality data (level I evidence), the 
decision to treat radiation cystitis with HBO and duration of treatment is still investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hyperbaric oxygen (HBO) therapy rendered on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on March 5, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one evaluation 
and management code is payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported.  
 
We looked at the file and Medicare rules. As an evaluation and management service, provided by a physician 
in the same specialty in the same group, has already been paid for this date of service, the requested services are not payable. 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 (99285) provided on 
March 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87804, 87811) provided on November 13, 
2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 87804, & 87811 are not supported in the medical record. Specifically, no lab results 
are provided for the billed tests. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(87804, 87811) provided on November 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4 units of code 87481 billed for May 11, 2022. 
 
You asked the Plan to pay for 4 units of code 87481. The Plan denied your request. The Plan says the number 
of billed units is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 4 units of code 87481 Our reviewer says that 
the records provided do not support 4 units of code 87481. Our physician reviewer found that according to the 
test results in the medical record, 3 candida species were tested. This supports 3 units of code 87481.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 units of code 87481 have not been met. Therefore, we decided that the Plan 
does not have to pay for 4 units of code 87481 billed for May 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the right ultrasound (76882-GZ) and left ultrasound (76882-
GZ) provided on March 1, 2023. 
 You asked the Plan to pay for the ultrasounds. The Plan denied your request. The Plan says the services were 
billed with GZ modifiers. The Plan also says that claim lines with a GZ modifier are automatically denied as 
non-covered services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that Medicare 
contractors that process both institutional and professional claims have discretion to automatically deny claim 
line(s) items billed with the GZ modifier. 
 
We find that CPT code 76882-GZ is not supported in the medical record. Specifically, CPT 76882-GZ is not 
supported as it was billed with a modifier that indicates it is not covered. Based on this information, we decided 
that Medicare rules for coverage of the ultrasounds have not been met. Therefore, we decided that the Plan 
does not have to pay for the right ultrasound (76882-GZ) and left ultrasound (76882-GZ) provided on March 1, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electromyography provided on March 16, 2022. 
 
You asked the Plan to pay for electromyography. You say that electromyography was medically necessary. The 
Plan denied your request. The Plan says electromyography is not a covered benefit for intraoperative testing 
during spinal surgery as the necessity and reasonableness of EMG studies shortly after trauma, before EMG 
abnormalities would have reasonably had time to develop has not been established. 
 
The Plan follows Medicare rules. Medicare rules say that electromyography is covered when the criteria listed 
in the Medicare rules section of this decision 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 pay for electromyography. Our reviewer says that 
the requested electromyography is not considered medically necessary in this case. Our physician reviewer 
found that there is insufficient evidence demonstrating that electromyography impacts outcomes in the setting 
of posterior cervical spinal fusion. The clinical documentation does not support that electromyography was 
medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electromyography have not been met. Therefore, we decided that the Plan does 
not have to pay for electromyography provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that in consideration of the enrollee's prior medical 
history, active comorbidities, and risk for medical instability while increasing activity the IRF setting is the 
most appropriate to reach the desired outcomes. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare guidelines 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
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 enrollee has post-traumatic stress disorder with 
multiple medical diagnosis with documentation. The Plan denied your request. The Plan says the SNF services 
requested do not meet the requirements for approval. 
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 
setting. Required services can be provided in the home, in an assisted living facility with home health care, or 
in a long-term care facility on a part time basis. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
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 that there is no documentation provided indicating the medical necessity for 
admission to an LTACH. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy (E0691) provided on 
March 22, 2023. 
 
You asked the Plan to pay for the UV light therapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 UV light therapy. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rational for the requested therapy. 
 
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 UV light therapy have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultraviolet (UV) light therapy (E0691) provided on March 22, 2023.