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

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator leads (K1019) provided on 
December 13, 2022. 
 You asked the Plan to pay for the Cala Trio nerve stimulator leads. You say that the enrollee has been using the 
Cala Trio device and seeing improvement and control over their hands' essential tremor. The Plan denied your 
request. The Plan says this denial was appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that the use of electrical nerve stimulation for motor 
function disorders is not proven medically effective. 
 
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 Cala Trio nerve stimulator leads. Our 
reviewer says that the Cala Trio stimulator leads (K1019) are not medically necessary. Our physician reviewer 
found there is insufficient evidence in the literature that this Cala Trio device is effective for the enrollee. The 
requested Cala Trio is not the standard of care for this enrollee's tremor according to current guidelines.  
 
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 Cala Trio nerve stimulator leads have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cala Trio nerve stimulator leads (K1019) provided on December 13, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MRA of the head. 
 
You asked the Plan to pre-approve the MRA. You say that the most important imaging request was denied. 
This procedure is needed to see if your seizures are coming from your brain. The Plan denied your request. The 
Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRA. Our reviewer says that the 
requested MRA is not medically necessary. Our physician reviewer found that the records show no indication 
that you have a condition of the head or neck for which surgery would be found to be appropriate. There was 
nothing within your history or on exam to suggest the presence of tumor, aneurysms, vascular malformations, 
vascular occlusion or thrombosis. The criteria for coverage have not been 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 the MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a MRA of the head.
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. The Plan denied your request. The Plan says the enrollee does not 
need a rehabilitation doctor to oversee your care three times a week. 
 
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. 
 
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: 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 the enrollee is unable to go to a lower level of care 
and requires an IRF admission. 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and are unable to care for yourself. 
You also say the requested IRF services are necessary for you to be able to go home. The Plan denied your 
request. The Plan says admission to the IRF is not medically necessary.  
 
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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have 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 you 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on December 29, 2022. 
 
You asked the Plan to pay for the service. You say that you billed these claims for two different physicians that 
have two different specialties. The Plan denied your request. The Plan says the provider did not bill as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the file shows that code 99223 was billed with a total of 2 units. One (1) unit was billed under one 
claim and 1 unit was billed under another claim for a total of 2 units. The appellant is stating that they billed 
these claims for two different physicians that have two different specialties; however, the claim forms show 
that both of them were billed for the same cardiologist. Per the CMS Practitioner Services MUE Table that was 
in affect at the time of this DOS, the allowed amount of units per day for this code is 1. Per the NCCI Manual, 
Chapter 1, Section V, If contractors have evidence (e.g., medical review) that UOS in excess of the MUE 
value were actually provided, were correctly coded and were medically necessary, the contractor may bypass 
the MUE for a HCPCS code with an MAI of 3. Per NCCI coding manual Chapter 11, Section U, point 
number 3, A provider/supplier may report only one per diem E&M service from a range of per diem codes 
on a single date of service. 
 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. 
Therefore, we decided that the Plan does not have to pay for initial hospital care (99223) provided on 
December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service December 
14, 2022. 
 You asked the Plan to pay for procedure code 99232. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99232 is bundled into payment for code 99239. 
 
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 99232 
is a column II code to column I code 99239. 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 99232 billed for date of service December 14, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650) and knee orthosis 
(L1851). 
 
You asked the Plan to pre-approve a lumbar-sacral orthosis and knee orthosis. The Plan denied your request. 
The Plan says the charts supplied did not comment on any back or knee issues or abnormal exam. The Plan also 
says the information provided did not meet Medicare rules. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis (L0650) is covered when it is 
ordered for one of the indications listed in the Medicare rules section of this letter. Medicare rules also say that 
claims for L1851 will be denied as not reasonable and necessary when the beneficiary does not meet the 
criteria for coverage listed in the Medicare rules section of this letter. 
 
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 lumbar-sacral orthosis and knee 
orthosis. Our physician reviewer found the record offers no complaints of back or knee joints and there is no 
physical exam of the relevant body parts. Our reviewer also found that the record does not provide evidence 
that the requested orthoses are reasonable and necessary for the enrollee. 
 
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 lumbar-sacral orthosis and knee orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650) and knee orthosis (L1851).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dextroamphetamine and amphetamine. 
 
You asked the Plan to pre-approve dextroamphetamine and amphetamine. You say that the claim should be 
reprocessed. The Plan denied your request. The Plan says that self-administered drugs do not fall under 
Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve dextroamphetamine and 
amphetamine.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the record did show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two 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 been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection.  
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case.  
Our physician reviewer found that in this case, there is no documentation that the enrollee had pain relief for at 
least three months from the previous ESI. There is no indication that the injection failed, and a new approach is 
being considered. The review has determined that the requested ESI does not meet the Medicare LCD coverage 
criteria. 
 
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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service February 25, 
2022, to March 26, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 25, 2022. The NOA was not received by the Plan until November 
16, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service February 25, 2022, to March 26, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), gel pads (K0108), and transfer handles (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, gel pads, and 
transfer handles. You say that these electronics are necessary for the power wheelchair. You also say that a 
split decision should be possible for the gel pads and transfer handles. The Plan denied your request. The Plan 
says that the electronic connection, expandable controller and expandable controller harness cannot be covered 
as it is not medically necessary to control the three approved power options through the joystick (drive 
interface). The Plan also says the gel pads and transfer handles serve no medical purpose and cannot be 
approved.  
 
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 an electronic connection, harness, 
expandable controller, gel pads, and transfer handles. Our reviewer says that the requested items/services are 
considered medically reasonable and necessary in this case. Our physician reviewer found the expandable 
controller with harness and electronic connection are necessary to operate the group 3 power wheelchair base 
and the three power options, including, tilt, recline and elevating leg rests, via a joystick. Additionally, the gel 
pads are needed to reduce friction and the chance of skin breakdown, and the transfer handles are needed given 
that the patient can provide some assistance when performing transfers. Our reviewer found that therefore, the 
expandable controller (E2377) with harness (E2313) and electronic connection (E2311) is medically necessary. 
Our physician reviewer also found that the gel pads (K0108) and transfer handles (K0108) are 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 an electronic connection, harness, expandable controller, gel pads, and transfer 
handles have been met. Therefore, we decided that the Plan has to pre-approve an electronic connection 
(E2311), harness (E2313), expandable controller (E2377), gel pads (K0108), and transfer handles (K0108).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 8MG tablet (J8597). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Review of the file shows that this medication is not being initiated within two (2) hours of the 
administration of chemotherapy and continued for a period not to exceed 48 hours from that time and this 
medication is not being used as a full therapeutic replacement for intravenous (IV) anti-emetic therapy that 
would have been administered at the time of the cancer chemotherapy treatment. Therefore, we decided that the 
Plan does not have to pre-approve Ondansetron 8MG tablet (J8597).  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 22, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes R06.00 and 
J96.01. Diagnosis code R06.00 has an Excludes1 note and cannot be billed with diagnosis code J96.01. 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 January 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99305 billed for date of service October 27, 
2022. 
 You asked the Plan to pay for procedure code 99305. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99305 is bundled into payment for code 99221. 
 
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 99305 
is a column II code to column I code 99221. 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 99305 billed for date of service October 27, 
2022.