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

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1851). 
 
You asked the Plan to pre-approve a knee orthosis. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis (L1851) is covered when the criteria 
listed in the Medicare rules section 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 knee orthosis. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the enrollee is ambulatory but the 
documentation does not reveal evidence of left knee objective joint laxity or instability on a physical 
examination. There is no evidence of a recent injury or surgery to the left knee.  
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1851).
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 a home ventilator. You say that you need the ventilator to assist with 
breathing and to prevent death. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary for this enrollee because their needs can be met with an alternative device such as a BiPAP device 
with average volume assured pressure support (AVAPS.)   
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee has diagnoses of 
COPD, obesity hypoventilation syndrome, obstructive sleep apnea, and reduced ejection fraction (HFrEF.) The 
enrollee was recently hospitalized with exacerbation of COPD and congestive heart failure. The enrollee has 
BiPAP at home, but notes indicate has not been compliant with using it. There are no pulmonary function tests 
to confirm the diagnosis of COPD and assess severity. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. There is no documentation of failure of BiPAP as an outpatient, and BiPAP with 
average volume assured pressure support (AVAPS) has not been tried. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. There is no reason to expect that switching 
from BiPAP to a home ventilator will improve the patient's compliance. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hillrom Life2000 device. 
 
You asked the Plan to pre-approve a Hillrom Life2000 device. You say that the enrollee requires continued 
access to durable medical equipment in order to prevent continued pulmonary exacerbations and 
hospitalizations. The Plan denied your request. The Plan says the Hillrom Life2000 device is not reasonable 
and necessary. A review of the current medical literature does not consider this device to be standard medical 
treatment for the enrollee's condition. The Life2000 system is not a true ventilator because it is not capable of 
providing full ventilatory support. It is designed primarily for use during activity. There is insufficient evidence 
of benefit in the treatment of your COPD, and no documentation that the enrollee has failed CPAP or BiPAP 
therapy.  
 
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 Hillrom Life2000 device. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found the enrollee 
has severe COPD.  The Life2000 system is not a true ventilator because it is not capable of providing full 
ventilatory support.  It is intended to be used during activity, and there is inadequate evidence that it is 
beneficial in the treatment of any chronic lung disease. 
 
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 Hillrom Life2000 device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Hillrom Life2000 device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 2, 2022, 
to December 12, 2022. 
 
You asked the Plan to pay for the home health services. You say that the records support the code billed. The 
Plan denied your request. The Plan says the records do not support the billed health insurance prospective 
payment system (HIPPS) code. 
 
The Plan follows Medicare rules. Medicare rules say that a case-mix methodology adjusts the 30-day payment 
rate based on characteristics of the patient and his/her corresponding resource need. 
 
 
 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 home health services. Our reviewer says 
that the documentation does not support the diagnosis code billed. Our physician reviewer found that the 
documentation does not support the correct patient driven payment model (PDPM) HIPPS code was submitted 
by the organization. The documentation indicates that the primary diagnosis code was not represented in the 
clinical documentation received. The primary diagnosis code of G82.50 (quadriplegia, unspecified) did not 
appear to be related to the skilled services. The partial adjustment to PDGM HIPPS code was appropriate. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from December 2, 2022, to December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laboratory panel rendered on April 4, 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. 
 
We find that CPT codes 87481, 87500, 87653, 87640, 87641, 87653, and 87798 are not supported in the 
medical record. Specifically, reporting multiple codes for this panel is inappropriate. A single code should have 
been used. 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 a laboratory panel rendered on April 4, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 14040 rendered on February 17, 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 14040 is "Adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less." 
 
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 the procedure report does not 
include sufficient documentation to verify procedure and measurements. The operative report describes undermining, which would not be reported with adjacent tissue transfer. 
 
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 code 14040 rendered on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307 and 83789) billed for 
date of service June 6, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says code 83789 is not separately payable, and codes G0480 and 
80307 are not supported in the records provided. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers 
performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures. The CPT Code Manual definition of code G0480 is drug test(s), 
definitive, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, the records provided do not include test 
results for any presumptive or screening drug tests. Without these results, we cannot verify the services were 
provided as billed. Code G0480 is not supported, as the records show that drugs from more than 7 classes were 
tested. There is a more appropriate code to report the services provided. In addition, we find that the testing 
described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for 
drug testing services (G0480, 80307 and 83789) billed for date of service June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan, guided tissue regeneration, and bone replacement graft (D0366, D4267, D7953) provided on May 18, 2023.

You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall within your dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan, guided tissue regeneration, and bone replacement graft (D0366, D4267, D7953) provided on May 18, 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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy  and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee suffers from chronic vertigo, 
chronic neck pain and chronic shoulder pain. You say the physical therapy sessions have been successful in 
providing the enrollee with relief. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. The enrollee has had extensive prior therapy for this condition including 
instruction in a home exercise program. The enrollee does not require the ongoing skills of a professional 
therapist.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798 rendered on February 
13, 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 denied codes remain 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 the denied codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 the laboratory report does not 
include any documentation for a rationale for using modifier XU - unusual non-overlapping service, to bypass 
the edit with CPT 87801. 
 
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 87481, 87653, 87798 rendered on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on March 9, 2023. 
 
You asked the Plan to pay for the pathology services. You say that the services were billed correctly.  The Plan 
denied your request. The Plan says this claim was billed with a primary diagnosis code that is not appropriate.  
 The Plan must follow Medicare rules. Medicare rules say that certain diagnosis codes are manifestation codes 
and should not be sequenced before the etiology code. These codes have a "Code first" note. 
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I85.10, secondary 
esophageal varices. This code has a "Code first" note indicating to report the underlying disease first. As such, 
it is not an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for 
coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay 
for the pathology services provided on March 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating the medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77002, J1240, and Q9966 rendered on 
January 10, 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 77002: 
 
Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) J1240: 
 
Injection, dimenhydrinate, up to 50 mg 
 
HCPCS Q9966: 
 
Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml 
 
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 CPT 77002 is an add-on code. An 
add-on code is only eligible for reimbursement if one of its primary codes is deemed eligible for 
reimbursement. In this case, no appropriate primary code was billed and deemed eligible for reimbursement by 
the same provider on the same date of service. Therefore, CPT 77002 is not eligible for reimbursement 
consideration. 
 
In terms of J1240, the records do not include sufficient documentation to validate that this injection was 
performed. Therefore, this code cannot be verified. 
 
Finally, in terms of Q9966, the records do not include sufficient documentation to validate that service was 
performed. This code cannot be verified. 
 
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 77002, J1240, and Q9966 rendered on January 10, 2023.