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

 
We decided that the Plan does not have to pre-approve compression bandages and conforming bandages 
(A6448, A6449, A6441, A6450, A6445, A6442, and A6443). 
 You asked the Plan to pre-approve compression bandages and conforming bandages. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says these items are not covered 
when they are not being used for surgical purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for surgical dressings used for clinical 
conditions other than qualify wounds will be denied as statutorily non-covered. 
 
We looked at the file and Medicare rules. In this case the enrollee is not using the bandages for a qualifying 
wound. Based on this information, we decided that Medicare rules for coverage of compression bandages and 
conforming bandages have not been met. Therefore, we decided that the Plan does not have to pre-approve 
compression bandages and conforming bandages (A6448, A6449, A6441, A6450, A6445, A6442, and A6443).
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 need  rehabilitation services and has been in the 
hospital 4 additional days waiting for transfer. You need proper treatment as you had emergency surgery and 
needs the additional care from becoming paralyzed The Plan denied your request. The Plan says your 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 your 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: Unfavorable

 
We decided that the Plan does not have to pre-approve Quantitative Calcium Scoring (75571). 
 
You asked the Plan to pre-approve Quantitative Calcium Scoring. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare does not cover a screening CCTA for 
asymptomatic patients, for risk stratification or for quantitative evaluation of coronary calcium. 
 
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 Quantitative Calcium Scoring. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is insufficient 
support in the peer-reviewed literature demonstrating a significant benefit of computed tomography (CT) 
imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal management of this 
patient. As such, CT imaging of the heart without contrast material with quantitative evaluation of coronary 
calcium is considered experimental/investigational for the evaluation and management of this enrollee's 
medical condition. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Quantitative Calcium Scoring have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Quantitative Calcium Scoring (75571).
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 want more therapy for the enrollee so they can 
get stronger. You say the enrollee needs more therapy than they received at a skilled nursing facility. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on October 3, 2022, billed with 
codes 87798, 87640, 87641, 87681, 87500, 87481 and 87653. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on October 3, 2022, billed with codes 87798, 87640, 87641, 87681, 87500, 87481 and 87653.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral nutritional supplement (B4152). 
 
You asked the Plan to pre-approve an oral nutritional supplement. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve an oral nutritional supplement (B4152).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical (78815). 
 
You asked the Plan to pre-approve a PET scan. You say that the requested service is needed for the enrollee's 
care. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the 
health plan, there is no indication that the enrollee has a malignancy. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is insufficient data documented to 
confirm a PET scan is indicated at this time.  There are lesions present, but a PET scan will not aid in diagnosis 
and is not standard of care at this junction. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) for attenuation correction and anatomical (78815).
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 you are requesting reconsideration because 
it is crucial for the enrollee to use a ventilator that has alarms and backup batteries. The Plan denied your 
request. The Plan says the request is not medically necessary because the records show that the ordered settings 
for the new 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 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in an intelligent volume assured pressure support (IVAPS) 
mode which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial 
and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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: 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 were independent prior to your stroke and want 
the most aggressive level of rehabilitation to return as close to your prior level of function as possible. The Plan 
denied your request. The Plan says it is not clear that you can reasonably be expected to participate in 3 hours 
of intensive daily rehabilitation services, or that you can be expected to significantly improve in a short period 
of time.  
 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233, 99497) provided on February 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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. 
 
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 use of codes 99233 
and 99497 is not supported by the records provided. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of a high level, so code 99233 is 
not supported. The documentation does not support 99497, "with clear explanation and discussion of advance 
directives such as standard forms (with completion of such forms, when performed), by the physician or other 
qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate". 
 
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 the services (99233, 99497) provided on February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E0956, E0958, E1007, E1012, 
E1028, E2209, E2311, E2313, E2361, E2377, E2620, and E2622).  
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power options and 
additional items and accessories. The Plan denied your request. The Plan says the enrollee does not have 
medical need for the multiple power options included with the requested K0861 group 3 power wheelchair with 
multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as 
code K0861) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the PWC base is not covered, then related accessories will be denied. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the coverage criteria 
have not been met. Our physician reviewer found the enrollee has a neurologic disorder with functional 
deficits. The documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Our reviewer found 
that although the members condition may meet criteria for a PWC, the criteria for this specifically requested 
PWC with multiple power options including power tilt and recline are not met. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E0955, E0956, E0958, E1007, E1012, E1028, E2209, E2311, E2313, E2361, E2377, E2620, 
and E2622).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a critical care evaluation and management visit provided on 
January 14, 2023. 
 
You asked the Plan to pay for 99291. You say that this claim is billed correctly. The Plan denied your request. 
The Plan says code 99291 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 to 74 minutes. 
 
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 99291. Our reviewer says that this code does not meet criteria for payment. Our reviewer found the records do not include sufficient documentation to verify critical 
care services including critical care procedures and time spent for critical care. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99291 have not been met. Therefore, we decided that the Plan does not have to 
pay for a critical care evaluation and management visit provided on January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the Koya Dayspring Device for the treatment of 
lymphedema. 
 
You asked the Plan to pre-approve  the Koya Dayspring Device. You say that this device mimics manual 
lymph drainage for home treatment. The Plan denied your request. The Plan says the clinical value and 
effectiveness of Koya Dayspring device in the setting of chronic lymphedema has not been demonstrated in 
peer-reviewed literature. More research is needed to show safety and efficacy of this item before it can be 
considered medically necessary and reasonable. 
 
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 Koya Dayspring Device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found although there are some preliminary studies for the Koya device, this is 
hardly the standard of care currently and further research is needed to establish its efficacy. 
 
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 Koya Dayspring Device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve  the Koya Dayspring Device for the treatment of lymphedema.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service March 10, 
2023. 
 You asked the Plan to pay for procedure code 74018. You say that 74018 should be covered as billed because it 
is supported in the records and was billed with a modifier. The Plan denied your request. The Plan says 
payment for code 74018 is bundled into payment for code 74250. 
 
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, we have confirmed that code 74018 
is a column II code to column I code 74250. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74018 billed for date of service March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the order does not 
include specific list of drug classes to be tested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. The rules also 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. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Additionally, the documentation 
submitted does not contain a valid physician order or lab requisition for the billed drug testing. The records do 
not show exactly what testing was to be performed. Therefore, we decided that the Plan does not have to pay 
for the drug testing services provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 4, 2023, billed with 
procedure code 93971-RT-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 93971-RT-59 is duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the procedure report does not include 
documentation of duplex scan of extremity veins. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 4, 2023, billed with procedure code 
93971-RT-59.