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

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot-ankle feature and 
extra covering. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a prosthesis with K3 foot does not meet Medicare criteria as reasonable 
and 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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not discuss the enrollee's activity level and functions. The enrollee uses an 
assistive device (walker) which was not consistent with a K3 level of ambulation. The additional outer covering 
exceeds the enrollee's medical needs as the documentation does not support that the enrollee requires protection 
beyond a standard cover or needs protection from unusually harsh environmental situations. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a prosthetic leg with an advanced foot-ankle feature and extra covering.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV). 
 
You asked the Plan to pre-approve the requested NIV. You say that this is medically necessary since the device 
offered by the Plan will not meet the enrollee's needs.  The Plan denied your request. The Plan says there is no 
medical need for this NIV.  
 
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. 
 
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 requested NIV. Our reviewer says that the requested NIV is not medically reasonable and necessary. Our physician reviewer found the enrollee 
has COPD and was hospitalized in April with exacerbation. Arterial blood gases (ABG) were consistent with 
acute on chronic hypercarbic respiratory failure. The partial pressure of carbon dioxide (PaCO2) improved 
from 80 to 58 with bilevel positive airway pressure (BiPAP) and other treatments. There are no recent 
pulmonary function tests. There is no documentation of chronic CO2 retention with an ABG done while stable. 
If that is present, the enrollee may benefit from BiPAP with average volume-assured pressure support 
(AVAPS) during sleep. The records do not show that this has been tried. 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 the requested NIV have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a non-invasive ventilator (NIV).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from September 20, 
2022, to September 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
enrollee met the sepsis criteria You also say that the claim should be reconsidered. The Plan denied your 
request. The Plan says diagnosis code A41.9 is not supported, which resulted in a DRG change. 
 
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 diagnosis code A41.9, defined as sepsis unspecified 
organism. 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 billed diagnosis code is not supported. Our physician 
reviewer found the provided documentation does not include sufficient evidence of the enrollee having a 
dysregulated response to infection leading to life-threatening organ failure. The reviewer found that sepsis 3 
criteria was not met for this admission. Therefore, the reviewer found that diagnosis code, A41.9 (sepsis), is not 
supported in the documentation.   
 
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 from September 20, 2022, to September 25, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment cannot be 
made for service provided to incarcerated enrollees. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare excludes from coverage items and 
services furnished to beneficiaries in State or local government custody under a penal statute, unless, it is 
determined that the State or local government enforces a legal requirement that all prisoners/patients repay the 
cost of all healthcare items and services rendered while in such custody.   
We looked at the file and Medicare rules. The records show that the enrollee in this case is incarcerated. 
Neither Medicare or the Plan makes payment for services provided to incarcerated enrollees. 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 provided on December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA). 
 
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 PTA 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 services are not medically necessary. Our physician reviewer found there is limited narrative in the 
submitted records with respect to the details of the enrollees leg symptoms including laterality, nature, and 
location from which to assess medical necessity. The enrollee is described as having significant issues with 
heart failure and shortness of breath and it is not clear what represents his limiting factor with respect to 
walking distance. There is no evidence in the medical record suggesting limb threat.  Additionally, the 
documentation alludes to an upcoming intravascular procedure for treatment of a renal malignancy.  There is a 
request for clearance to stop antiplatelet medication for this. It would not be reasonable to undergo an elective 
lower extremity intervention just prior to having to discontinue antiplatelets and it is unclear if this renal 
procedure has been performed yet. Due to lack of clarity with respect to enrollees symptoms, unclear evidence 
that the enrollee would experience meaningful increase in his walking distance, and absence of objective 
evidence, the requested PTA is 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 percutaneous transluminal angioplasty (PTA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sit-to-stand lift.  
 
You asked the Plan to pre-approve the requested sit-to-stand lift. You say that this is necessary to allow the 
enrollee to get out of a chair. The Plan denied your request. The Plan says this is a noncovered item.  
 
The Plan must follow Medicare rules. Medicare rules say that patient lifts are covered when needed to transfer 
from bed when the enrollee would be otherwise bed-confined.  
 
We looked at the file and Medicare rules. This lift is not for transfer from bed. Medicare does not include 
coverage for lifts from a chair to standing. Based on this information, we decided that Medicare rules for 
coverage of the requested sit-to-stand lift have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sit-to-stand lift.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve single photon emission computed tomography (SPECT). 
 
You asked the Plan to pre-approve the SPECT. You say that you do not agree with this denial. The Plan denied 
your request. The Plan says that the requested SPECT is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SPECT. Our reviewer says that the 
request for SPECT is medically necessary. Our physician reviewer found the provided magnetic resonance 
imaging (MRI) findings do not match the enrollee's symptoms. Therefore, the reviewer found that the requested 
SPECT is 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 SPECT have been met. Therefore, we decided that the Plan has to pre-
approve single photon emission computed tomography (SPECT).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62321). 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain requirements 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested 
injection is not medically necessary. The history, physical examination, and radiological image-based 
diagnostic testing does not support a diagnosis of thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62321).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0482) rendered on 
October 10, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says under Medicare rules, the number of definitive urine drug classes requested are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that definitive drug testing was performed (15-21 drug classes) and is being requested. There was no 
evidence suggestive of drug abuse or misuse of multiple drug classes from history of point-of-care urine drug 
screening to justify definitive drug testing of 15-21 drug classes, when 1-2 drug classes would have sufficed in 
this clinical situation.  
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for drug testing services (procedure code G0482) rendered on October 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 1, 2022, to 
April 2, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient admission was not 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.Our 
physician reviewer found based on the low complexity, low severity, and quick response to initial treatment in 
the emergency department, it was not expected that the enrollee would require hospital services that would 
likely cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided April 1, 2022, to April 2, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87653. We decided that the Plan does not have to pay 
for procedure code 87481.  
 
You asked the Plan to pay for procedure codes 87481 and 87653 billed for date of service December 28, 2022. 
You say that these services were reported correctly and are supported in the medical record. The Plan says that 
these services are not supported for separate billing/reporting. 
 
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 decided that the Plan has to pay for procedure code 87653.  
 
In this case, we have confirmed that code 87653 is a column II code to column I code 87801; however, 87653 
was billed with a modifier.  
 
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 87653. Our reviewer says that this code is 
supported for separate reporting. Our reviewer found that CPT coding instructions state to use codes from the 
range 87471-87660 for specified organisms. The record supports that testing for group B strep was performed 
and was negative. According to CPT coding instructions for code 87801, for each specific organism nucleic 
acid detection from a primary source, see 87471-87660. Therefore 87653 is separately identifiable from 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 procedure code 87653 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87653.  
 
We also decided that the Plan does not have to pay for procedure code 87481. 
 
In this case, we have confirmed that code 87481 is a column II code to column I code 87801. This code 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 87481. 
 
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 pay for the pneumatic compression device provided on January 10, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a monthly subscription fee paid on January 19, 
2023.  
 
You asked the Plan to reimburse you for the monthly subscription fee. You say that your primary care provider 
has become out-of-network and is now independent. You say that there is a monthly fee associated with his 
coverage. You say that you should be allowed to choose your own physician since you are part of a Preferred 
Provider Organization (PPO) plan. You say that this physician has been your provider for 30 years and you 
trust him emphatically.  The Plan denied your request. The Plan says the requested provider does not accept 
Medicare and is therefore, not covered.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for a monthly subscription fee 
paid on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical facet joint injection. 
 
You asked the Plan to pre-approve the injection. You say that a facet injection targeting their occipital nerve 
and will provide the enrollee sustainable relief. The Plan denied your request. The Plan says  a cervical facet 
joint injection 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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has multiple other 
probable pain generators, and the pain is not primarily axial. Therefore, the request is not 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cervical facet joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service January 19, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 28 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service January 19, 2023.