Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option (K0861) and additional items and accessories (codes E0950, E0953, E0955, E1007, E1012, 
E1028, E2311, E2313, E2361, E2377, E2620, E2624, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options included with a K0861 group 3 power wheelchair. The Plan also says the electronic connection 
(E2311), harness (E2313), and expandable controller cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the group 3 power wheelchair with power tilt & 
recline is not medically necessary. Our physician reviewer found the enrollee requires a power wheelchair for 
mobility and accomplishing their daily activities. However, the clinical documentation is insufficient why a 
lower-level power wheelchair would not meet their needs versus a group 3 power wheelchair. There is 
inadequate clinical documentation regarding why they require power tilt & recline and cannot adequately 
perform pressure relief. Our reviewer found that there is no history of skin breakdown, and the enrollee 
requires only minimal assistance with transfers. Our physician reviewer also found that the evaluation indicates 
that the enrollee is functionally non-ambulatory, but their actual level of mobility is not specified. A group 3 
power wheelchair base is typically indicated in patients with significant paralysis due to conditions such as a 
spinal cord injury. 
 
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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power option (K0861) and additional items and accessories (codes E0950, E0953, 
E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2620, E2624, and K0040).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied home health skilled nursing services and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
noted to have difficulty taking their medications, but they are not complex medications to administer, and they 
have received education regarding medication management. This does not necessitate skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested injection is medically 
necessary. The Plan denied your request. The Plan says the enrollee's reported pain does not meet the criteria 
necessary for the injections to be approved. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case, there is documentation of radiculopathy. The review has determined 
that the enrollee does not meet the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95937 and G0453 rendered on May 9, 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 records do not support the services 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 the denied codes is: 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
Healthcare Common Procedure Coding System (HCPCS) G0453: 
 
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), 
per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary 
procedure) 
 
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 in terms of CPT 95937, the 
records support that train of four testing was provided during a cervical discectomy. The provided records do 
not document the required elements for CPT 95937 as detailed in the guidelines. 
 
In terms of G0453, the records do not support this as a separate and distinct procedure from CPT 95955. The 
records do not support that G0453 was provided during a different session or patient encounter, different 
procedure or surgery, different site, or organ system, separate incision/excision, or separate injury, as required. 
 
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 codes 95937 and G0453 rendered on May 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 3, 2023, to June 1, 
2023. 
 You asked the Plan to pay for the home health services. You say that you originally billed Original Medicare, 
which is why the NOA was late. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 3, 2023. The NOA was not received by the Plan until August 1, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
May 3, 2023, to June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Swift Microwave Treatment (28889). 
 
You asked the Plan to pre-approve a Swift Microwave Treatment. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this procedure is considered experimental. 
 
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 Swift Microwave Treatment. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental. 
 
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 Swift Microwave Treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Swift Microwave Treatment (28889).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests) and accessories.  
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
power options will best meet the enrollee's needs for safer, independent activities of daily living completion in 
their home. You say that the enrollee will be better able to reposition their body through the day to increase 
sitting tolerance and weight shift independently. You also say that the power options will allow the enrollee to 
reposition independently to alleviate neuropathic pain, muscle spasms and proper weight shifting. The Plan 
denied your request. The Plan says the enrollee does not have a medical need for multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested a Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found provided medical records from the enrollee's 
treating physician do not corroborate that the enrollee is high risk for skin breakdown, has a history of pressure 
ulcer(s) or has had skin flap surgery. The physician records report a "negative "neurological review of systems 
without "gait disturbance" and that the enrollee walks for exercise 3 to 4 times per week. Provided medical 
records from the enrollee's treating physician do not corroborate that the enrollee performs bladder self-
catheterization and is unable to transfer independently or that they have increased muscle tone or spasticity to 
meet criteria for the power tilt and/or recline and thus the multiple power option base (K0861). Therefore, the 
reviewer found that the requested Group 3 power wheelchair with multiple power options is not medically 
reasonable or necessary. As the requested wheelchair base does not meet Medicare coverage criteria, the 
requested accessories are not covered. 
 
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 Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrests) and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76377 billed for date of service May 15, 
2023. 
 
You asked the Plan to pay for procedure code 76377. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 76377 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation. 
 
 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 76377. Our reviewer says that documentation 
does not support that 76377 was performed. Our reviewer found the records provided do not contain a 
description of an interpretation and report of 3D rendering with image postprocessing on an independent 
workstation. It cannot be verified that this service was performed. 
 
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 76377 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76377 billed for date of service May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the BK acrylic socket (L5629), total contact (L5637), flexible 
inner socket and external frame (L5645), distal cushion (L5668), supracondylar suspension (L5670), ultra-light 
material (L5940). 
 
You asked the Plan to pre-approve the BK acrylic socket (L5629), total contact (L5637), flexible inner socket 
and external frame (L5645), distal cushion (L5668), supracondylar suspension (L5670), ultra-light material 
(L5940). You say that the items should be covered. The Plan denied your request. The Plan says that  the 
features of these codes are accounted for in the base code and represent unbundling.  
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 BK acrylic socket (L5629), total 
contact (L5637), flexible inner socket and external frame (L5645), distal cushion (L5668), supracondylar 
suspension (L5670), ultra-light material (L5940). Our reviewer says that the items are medically necessary. Our 
physician reviewer found nothing about the L5020 code description nor its more practical discussion in the 
Policy Article mentions any of the attributes described by the codes in question. Indeed, each and every one of 
them represents a distinct and standard feature of modern, laminated, custom fabricated sockets. All of the 
codes requested by the CPO are reasonable, necessary, and do not in any way represent unbundling from 
L5020. 
 
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 BK acrylic socket (L5629), total contact (L5637), flexible inner socket and 
external frame (L5645), distal cushion (L5668), supracondylar suspension (L5670), ultra-light material 
(L5940) have been met. Therefore, we decided that the Plan has to pre-approve the BK acrylic socket (L5629), 
total contact (L5637), flexible inner socket and external frame (L5645), distal cushion (L5668), supracondylar 
suspension (L5670), ultra-light material (L5940).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439).  
You asked the Plan to pre-approve Injectafer. You say that Injectafer is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Injectafer have 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 Injectafer. Our reviewer says that 
treatment with Injectafer is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug. In this 
case, 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Injectafer (J1439).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an OssDsign Catalyst Synthetic Bone Graft Allograft 
(20930). 
 
You asked the Plan to pre-approve an OssDsign Catalyst Synthetic Bone Graft Allograft. You say that this is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
OssDsign Catalyst Synthetic Bone Graft in the setting of a spine fusion surgery have 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 an OssDsign Catalyst Synthetic Bone 
Graft Allograft. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. 
Further studies are needed to corroborate that the requested allograft would be as safe or better than standard 
autograft procedures. There is no compelling rationale presented, or extenuating circumstances noted to support 
the medical necessity of this request as an exception. 
 
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 OssDsign Catalyst Synthetic Bone Graft Allograft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an OssDsign Catalyst Synthetic Bone Graft 
Allograft (20930).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Vacuum Assisted Socket System (VASS) (L5781). 
 
You asked the Plan to pre-approve the VASS. You say that the item is medically necessary. The Plan denied 
your request. The Plan says that the item is considered experimental. 
 
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 the VASS. Our reviewer says that the 
requested item is considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee's need for all the requested parts of this prosthesis is adequately described by the medical record. 
 
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 VASS have been met. Therefore, we decided that the Plan has to pre-
approve the Vacuum Assisted Socket System (VASS) (L5781).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided by a chiropractor on May 
17,2023. 
 
You asked the Plan to pay for the office visit (99203). You say that you were told that your chiropractic care 
was 100% covered. The Plan denied your request. The Plan says the only covered chiropractic service is 
manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided by a chiropractor on May 17,2023.