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

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T11 and L1. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the enrollee has lower back pain. The Plan 
denied your request. The Plan says the enrollee does not meet the medical criteria needed for this procedure. 
 
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 kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no trial of a back brace for fracture treatment. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at T11 and L1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dry pressure mattress (E084), provided by a skilled 
nursing facility on April 30, 2023. 
 
You asked the Plan to pay for the dry pressure mattress. You say that the item should be covered. The Plan 
denied your request. The Plan says this item is not covered when obtained through a provider that is not 
enrolled in Medicare as a DME supplier. 
 
The Plan must follow Medicare rules. Medicare rules say that a Durable Medical Equipment (DME) supplier 
must, among other things, meet the following conditions to be eligible to receive payment for a Medicare-
covered item: (i) the supplier has submitted a complete Form CMS-855S (including all supporting 
documentation) to the applicable contractor); and (ii) the item was furnished on or after the date the contractor 
issued to the supplier a DME supplier number conveying Medicare billing privileges.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the dry pressure mattress have not been met. Specifically, this item was obtained through a provider that is not enrolled in Medicare as a DME supplier. Therefore, we decided that the Plan does not have 
to pay for the dry pressure mattress (E084), provided by a skilled nursing facility on April 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mitral valve replacement (MVR), tricuspid valve 
replacements (TVR), and surgical ablation of atrial fibrillation (SAAF). 
 
You asked the Plan to pre-approve the surgical services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show that the enrollee has a severely 
leaking valve in their heart. The Plan also says that the related inpatient hospital admission 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 surgical services. Our reviewer says 
that the requested mitral valve replacement (MVR), tricuspid valve replacements (TVR), and surgical ablation 
of atrial fibrillation (SAAF) are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation shows a trans-thoracic echocardiogram with hemodynamic data 
from February 2023 showed structurally normal mitral and tricuspid valves, with trace mitral regurgitation and 
mild-moderate tricuspid regurgitation. A trans-esophageal echocardiogram from June 2023 showed severe 
mitral regurgitation, mild-moderate tricuspid regurgitation, and mild-moderate aortic regurgitation; it did not 
provide hemodynamic data documenting the severity of the valvular lesions. As such, the documentation is 
inconsistent and would not confirm that the valvular disease is of sufficient severity to warrant valve 
replacement. Therefore, the reviewer found that the requested MVR/TVR/SAAF procedures are not medically 
reasonable and 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the mitral valve replacement (MVR), tricuspid valve replacements (TVR), and 
surgical ablation of atrial fibrillation (SAAF).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug test(s), 1-7 drug class(es) (G0480) provided June 13, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the medical records submitted do not include an order that specifically list what 
test(s) are to be performed in the custom panel. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file does contain an order that specifically lists what test(s) are to 
be performed. Therefore, we decided that the Plan has to pay for the drug test(s), 1-7 drug class(es) (G0480) 
provided June 13, 2023.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from October 12, 2023, forward. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal 
supervision. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs can, as a practical matter, be provided at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care from October 12, 2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cystourethroscopy, with ureteroscopy and/or 
pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (52356) to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a cystourethroscopy. You say that the enrollee is experiencing pain from 
kidney stones and needs to have service with the requested provider who is only contracted with this facility. 
 The Plan denied your request. The Plan says the enrollee must use network providers to get your medical care 
and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling 
ureteral stent (52356) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high strength, lightweight wheelchair (K0004) and 
additional items and accessories (codes K0108, E0951, and K0040, E2211, E2213, K0108, E0961, E0973, 
E0971, E0978, and E2601). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you feel that you need 
a manual chair, as well as a power chair because if you want to go out to dinner, you cannot put your power 
chair on the car. You also say that you do not have the money to pay for a manual wheelchair because you are 
on a fixed income. The Plan denied your request. The Plan says according to the available information, the 
requested manual wheelchair is for backup, and there is no indication the primary power wheelchair is in 
disrepair. 
 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 the durable medical equipment (DME). 
Our physician reviewer found the wheelchair is not medically necessary to facilitate self-care in the home. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high strength, lightweight wheelchair (K0004) and 
additional items and accessories (codes K0108, E0951, and K0040, E2211, E2213, K0108, E0961, E0973, 
E0971, E0978, and E2601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional items and accessories (codes E1007, E2361 x2, E1028, E2620, E0955, E1028, E1012, E1028 x2, E0953 x2, 
E2377, E2313, E2311, and E2607). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you are submitting an 
appeal on behalf of the client so the client can get the equipment/devices they need to help make their daily 
lives for the better. The Plan denied your request. The Plan says there is still a lot of Medicare criteria that has 
not been 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 the durable medical equipment (DME). 
Our physician reviewer found the record does not support the enrollee has high risk for skin breakdown, use a 
catheter intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 standard power wheelchair, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional 
items and accessories (codes E1007, E2361 x2, E1028, E2620, E0955, E1028, E1012, E1028 x2, E0953 x2, 
E2377, E2313, E2311, and E2607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
November 3, 2022, to November 22, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says this service 
does not meet the medically necessary criteria. 
 
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 the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided November 3, 2022, to 
November 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 25600 and 99233 rendered from January 31, 2023, to 
February 1, 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 that 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 25600: 
 
Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed 
treatment of fracture of ulnar styloid, when performed; without manipulation 
 
CPT 99233: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee was noted to be placed in 
an short arm-post mold volar brace. Therefore, the documentation does support that CPT 26500 was rendered 
in this case. 
 
Additionally, the records do support CPT 99233 in this case. The enrollee was placed in physician observation 
at 19:09 on January 30, 2023. The note continues into 1/31/21, with noted continued physician observation 
with no events during this period of observation. Observation is noted to continue through 2/1/23 (08:18) when 
she was discharged. Therefore, the documentation does support that CPT 99233: subsequent hospital inpatient 
or observation care, per day, for the evaluation and management of a patient, which requires a medically 
appropriate history and/or examination and high level of medical decision making, when using total time on the 
date of the encounter for code selection, 50 minutes must be met or exceeded was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 25600 and 99233 rendered from January 31, 2023, to February 1, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you feel this should be 
approved. The Plan denied your request. The Plan says a pneumatic compression device for prevention of deep 
vein thrombosis (DVT) is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the chest. 
 
You asked the Plan to pre-approve the CT scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
request is not medically necessary. Our physician reviewer found that the enrollee had CT of the chest on 
9/23/22 and when compared to a prior exam of 6/23/21 there had been no change in a 15mm partially calcified 
left upper lobe nodule diagnosed as a granuloma. Absent the review of CT reports prior to 9/22/22 the medical 
necessity of the requested CT of the chest can't be determined. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT scan of the chest.
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 SNF admission is medically necessary.  The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for SNF admission. 
 
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 not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for April 7, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0481 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 G0481 is definitive drug testing, 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation 
of the appropriate method of testing for the billed code. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0481 billed for April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography (procedure code 93312) rendered on 
February 15, 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 code 93312 is "Echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); including probe placement, image 
acquisition, interpretation and report." 
 
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 a review of the medical records 
submitted does not reveal sufficient documentation to support the use of CPT 93312. 
 
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 echocardiography (procedure code 93312) rendered on February 15, 2023.