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

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, below knee/above knee, 
custom fabricated socket insert for congenital or atypical traumatic amputee (L5681). 
 
You asked the Plan to pre-approve custom fabricated socket insert. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not cover this type of insert with a replacement 
prosthesis. 
 
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 custom fabricated socket insert. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this coding distinction is relevant because the allowable amount for L5681 
is higher than the allowable amount for L5673, reflecting the higher upfront costs of making the first custom 
fabricated socket insert for a given enrollee compared to the costs of making subsequent copies of that same 
insert. Though the request for 2 replacement inserts for this enrollee is reasonable and necessary per the LCD 
and Policy Article, the coding the certified prosthetist/orthotist (CPO) should have used would have been 
L5673 x2, given that no new mold/measurements are being taken, and the inserts to be delivered will be mere 
copies of the one first custom designed in 2022. The CPO is encouraged to submit a new request for an 
additional L5673. On the other hand, if appealing, she would need to document exactly how new 
molds/measurements are figuring into this request for new custom fabricated socket inserts. Therefore, at this 
time and per the record provided, the Plans denial of L5681 is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of custom fabricated socket insert have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an addition to lower extremity, below knee/above knee, custom 
fabricated socket insert for congenital or atypical traumatic amputee (L5681).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that the requested services were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the service is medically necessary. Our physician reviewer found It did appear that 
active treatment was taking place. It did appear that the services were reasonably expected to improve the 
enrollees condition or for the purpose of diagnosis. Based upon review the records provided for the admission 
of this enrollee does meet criteria for acute inpatient mental health treatment as although this enrollee was not 
shown to be a danger to himself or others, with no auditory or visual hallucinations the enrollee did have 
bizarre delusions and was difficult to manage in the emergency department. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric care.  
 
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 an electric lift described by code E0635. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an electric lift is covered when specific 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have a 
compression fracture of the spine and chronic pain. The criteria for coverage of the electric lift are not met, as 
you are able to walk 100 feet with assistance. The services are therefore not reasonable or medically necessary 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electric lift described by code E0635.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 24, 2023, to 
March 28, 2023, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have billed the services at issue correctly. The Plan denied your request. The Plan says criteria for payment at 
the DRG originally billed have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code I63.9, Cerebral infarction, 
unspecified, and secondary diagnosis code L03.112, Cellulitis of left axilla. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the inpatient hospital services do not meet criteria for payment at the DRG originally billed Our physician 
reviewer found that in this case there was no clinical or radiographic evidence of cerebral infarction. The 
enrollee was diagnosed with a transient ischemic attack. There was no clinical or laboratory evidence of 
cellulitis. The documentation does not support principal diagnosis code I63.9 and secondary diagnosis code 
L03.112.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 24, 2023, to March 28, 2023, at the DRG originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing code 87633 billed for date of service February 
10, 2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed service have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing code 87633 billed for 
date of service February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that  the items are medically 
necessary. The Plan denied your request. The Plan says the clinical records do not support that the enrollees 
lymphedema extends to the chest, trunk or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652, E0657).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited appeal for the 
denial of a SNF admission. The Plan denied your request. The Plan says that the services requested are not 
covered.  
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has dementia and a significant decline in function. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x2). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says 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 clinical 
documentation shows that the enrollee has functional impairments however there are no specified clinical 
needs (wound assessments, medication changes) that would be expected to require 2 additional home health 
nursing visits thus the records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in the home setting in order to improve the enrollee's condition, or to 
establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
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 skilled nursing (G0299 x2).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 7, 2023. 
 
You asked the Plan to pay for the ambulance services and ground mileage. You say that the service was 
provided to the enrollee for medical necessity. The Plan denied your request. The Plan says based on the 
information, we decided that Medicare rules for coverage of the non-emergency ambulance transportation and 
ground mileage have not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance services and ground mileage. 
Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
transportation via ambulance upon hospital discharge was not medically necessary.  The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's condition. A prudent layperson would not 
believe that immediate medical attention was required for someone who was being discharged from the 
hospital. 
 
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 ambulance services and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and chronic respiratory failure. The documentation shows that the ventilator is to 
be ordered for bi-level positive airway pressure (BiPAP) therapy. Medicare does not cover a home ventilator 
for this setting. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs this type of equipment 
for a better quality of life. The Plan denied your request. The Plan says the request is not medically necessary 
because the records show that the ordered settings for the noninvasive ventilator show it is going to be used 
only in a bi-level pressure mode. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of COPD 
and was recently hospitalized with respiratory failure requiring intubation. Arterial blood gases were consistent 
with acute on chronic hypercarbic respiratory failure. The enrollee has a percutaneous endoscopic gastrostomy 
(PEG) tube because of chronic aspiration. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. There are no pulmonary function tests to assess the severity of the airways obstruction. This enrollee 
may benefit from BiPAP with average volume assured pressure support (AVAPS) during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service December 1, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 99233. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented to the emergency 
department with altered mental status and disorientation. The documentation did not support a detailed interval 
history and medical decision making of high complexity. Therefore, code 99233 is not supported. 
 
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 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 for date of service December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 15, 2023, billed with 
codes 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 15, 2023, billed with codes 81314 and 81345.