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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair, upgraded electronics, 
joystick, footplates, and cushion mount hardware. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that you want to appeal this denial. The 
Plan denied your request. The Plan says upgraded electronics are not medically necessary. The Plan says the 
high-resolution joystick and footplate are miscoded. The Plan also says that the lateral cushion mount hardware 
is already included with the approved cushions. 
 
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 wheelchair accessories. Our 
reviewer says that the requested upgraded electronics, joystick, footplates, and cushion mount hardware are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the provided records indicate that you are able to use your upper extremity and can operate and control the power options using the 
switches that are included in the basic wheelchair. The face-to-face examination with your medical provider 
does not indicate any specific medical conditions of deformities of the feet which would require the special 
large footplates requested as opposed to the standard footrests which come included with the already approved 
wheelchair and accessories. The reviewer also found that the approved power wheelchair includes cushion 
mount hardware. Therefore, the reviewer found that the requested upgraded electronics, joystick, footplates, 
and cushion mount hardware are 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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair, upgraded electronics, joystick, footplates, and 
cushion mount hardware.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on March 24, 2023. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The submitted documentation does not contain a valid physician 
order or lab requisition for the specific testing provided in this case. 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 drug testing provided on March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC gene expression test provided on 
March 27, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC gene expression test. You say that the DecisionDx-SCC 
gene expression test was medically necessary. The Plan denied your request. The Plan says the DecisionDx-
SCC gene expression test 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 DecisionDx-SCC gene expression test. Our reviewer says that the requested DecisionDx-SCC gene expression test is not considered medically 
reasonable and necessary. Our physician reviewer found that the DecisionDx-SCC genomic test measures the 
biological activity of specific genes in the tumor that tells how likely it is for the tumor to spread or 
metastasize. The review has determined that per the DEXTM Diagnostics Exchange Registry, this testing has 
been evaluated by the MolDX Program and is considered non-covered. The review has determined that the 
DecisionDx-SCC gene expression test at issue in this case is 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 DecisionDx-SCC gene expression test have not been met. Therefore, we 
decided that the Plan does not have to pay for the DecisionDx-SCC gene expression test provided on  
March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 20611 and J1040 for date of service May 9, 2023. 
 
You asked the Plan to pay for codes 20611 and J1040. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the documentation does not support the codes 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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting. 
 
The CPT Code Manual definition of code J1040 is injection, methylprednisolone acetate, 80 mg. 
 We find that CPT codes 20611 and J1040 are not supported in the medical record. Specifically, the medical 
records did not include documentation of the permanently recorded images; therefore, code 20611 cannot be 
verified. The National Drug Code (NDC) number submitted on the medical claim form does not match the drug 
documented; therefore, code J1040 cannot be verified. Based on this information, we decided that Medicare 
rules for coverage of codes 20611 and J1040 have not been met. Therefore, we decided that the Plan does not 
have to pay for codes 20611 and J1040 for date of service May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service February 20, 
2023. 
 You asked the Plan to pay for the billed services. You say that medical records were provided. 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the medical documentation provided does not include an evaluation and 
management of the critically ill/injured. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee needs to get to this 
appointment for a follow up visit for chronic kidney disease and hypertension. You also say that the enrollee 
has no other way to get to their appointments. The Plan denied your request. The Plan says this service is 
covered under the enrollee's benefit package, but exceeds the maximum count allowed per period.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Acetaminophen-Codeine tablet. 
 
You asked the Plan to pre-approve Acetaminophen-Codeine. You say that the requested drug is a medical 
necessity for the enrollee. 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Acetaminophen-Codeine tablet.  
 
Benefits for Acetaminophen-Codeine 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: 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 IRF admission is medically necessary.  The Plan 
denied your request. The Plan says you do not meet the 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF as 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train of four testing provided on April 6, 2023. 
 
You asked the Plan to pay for the testing. 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 95937 is "Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method". 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, code 95937 should not be 
used for train of four testing. Train of four testing is considered integral to the procedure and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the train of four testing provided on April 6, 
2023.
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 will benefit from continued skilled 
therapy and is requested for discharge to an inpatient rehabilitation facility. The Plan denied your request. The 
Plan says the enrollee's condition does not meet the Medicare guidelines.  The Plan says that the services 
needed may be provided safely in a lower 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service July 15, 
2022. 
 You asked the Plan to pay for the billed services. You say that the code was billed with the correct diagnosis 
code. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a primary 
diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes. Another diagnosis code should be 
sequenced before a manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F02.80, defined as 
dementia in other diseases classified elsewhere without behavioral disturbances. This code is not an appropriate 
primary diagnosis as the code definition includes in diseases classified elsewhere. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99309 billed for date of service July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a flex-walk system (L5981). 
 
You asked the Plan to pre-approve a flex-walk system (L5981). You say that the requested flex-walk system 
(L5981) is medically necessary.  The Plan denied your request. The Plan says that the enrollee does not meet 
criteria for a flex-walk system (L5981). 
 
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 flex-walk system (L5981). Our 
reviewer says that the requested flex-walk system (L5981) is medically necessary.  Our physician reviewer 
found the notes from June and July, corroborated by the physicians note from May 2023, more than satisfy 
Medicare requirements for documenting the enrollee's K3 functional potential as well as his need for the new 
prosthesis generally and the foot specifically. 
 
The LCD L33787 states simply ...flex foot system (L5981)...is covered for beneficiaries whose functional 
level is 3 or above.  No further specific documentation is required in the LCD, the Policy Article, or any of the 
relevant Medicare manuals because Medicares policy recognizes that flex-walk feet are part of the basic 
standard of care for all community K3 amputee ambulators given that the evidence of their benefits and 
superiority to less sophisticated alternatives are so well proven and long standing. There is no doubt that 
original Medicare would cover the requested prosthesis for this K3-level enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a flex-walk system (L5981) have been met. Therefore, we decided that the Plan 
has to pre-approve a flex-walk system (L5981).  
 
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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show complex rehabilitation needs 
requiring frequent evaluation by a rehabilitation physician or that you will require an intensive team for your 
care. The Plan says that the services needed may be provided safely in a lower 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services coded as 74018 billed for date of service 
December 5, 2022. 
 
You asked the Plan to pay for 74018. You say that 74018 should be covered because the enrollee had 2 
procedures on the same date of service and appropriate modifiers have been added. The Plan denied your 
request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Records support that 2 radiology services described 
by codes 74022 and 74018 were done by 2 separate practitioners of the same specialty and practice, on 
December 5, 2022. A National Correct Coding Initiative (NCCI) edit exists between column 1 code 74022 and 
column 2 code 74018. Originally, 74018 was billed without an appropriate NCCI associated modifier to bypass 
this edit, so it was denied. The provider then submitted a corrected claim for 74018 including the missing 
NCCI associated modifier. -XP was assigned to 74018, the column 2 code, indicating it was done by a different 
provider. Based on this information, we decided that Medicare rules for coverage of 74018 have been met. 
Therefore, we decided that the Plan has to pay for the radiology services coded as 74018 billed for date of 
service December 5, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305) provided on February 2, 2023. 
 
You asked the Plan to pay for pathology services. You say that these services were necessary and were reported 
appropriately. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R12 has an Excludes1 note in relation to R10.13. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88305) provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns - porcelain fused to high noble metal tooth #'s 
22 and 25 (D2750). 
 
You asked the Plan to pre-approve the crowns. You say that these two crowns are necessary to improve your 
oral health. The Plan denied your request. The Plan says there is no evidence of surface destruction on tooth 
due to caries or trauma of four surface and at least 50% of the incisal edge of the tooth. 
 
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. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 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 crowns. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there were no clinical notes included that 
state why the crowns are needed. Tooth number 22 shows a small filing, and tooth number 25 does not show 
any decay or fracture. Based off the information submitted D2750 for teeth numbers 22 and 25 are not 
medically reasonable or necessary, and do not meet the requirements for a crown. There is not more than 50% 
tooth structure damage noted on the x-rays. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns - porcelain fused to high noble metal tooth #'s 22 and 25 (D2750).