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

 
We decided that the Plan has to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you have similar equipment already approved. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the plan's main objection to this device is that the enrollee already has a similar device at home in 
working condition that could meet their needs. However, the plan fails to state what this device supposedly is. 
Meanwhile, the enrollee's handwritten appeal from 6/27/23 suggests that the enrollee believes this item is a 
wheelchair. The enrollee explicitly and credibly points out that they cannot get around inside the home with 
this wheelchair. A knee scooter is inherently smaller and more mobile across uneven surfaces than a 
wheelchair. It makes this scooter more suitable for mobility, even is a small house that is not Americans with 
Disabilities Act (ADA) compliant. It is specifically designed to unweight an injured foot. There is no evidence 
that the plan has any other equipment already in hand that could meet the enrollee's needs. The requested 
E0118 is 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 services have been met. Therefore, we decided that the Plan has to pre-
approve a crutch substitute (E0118).  
 
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: 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 admission to an LTACH is not medically 
necessary.  
 
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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services as medically appropriate at 
this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty with guidance. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee is in a severe amount of pain that is 
affecting quality of life. The Plan denied your request. The Plan says the enrollee has a history of multilevel 
disc disease. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty may be covered if certain 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found the imaging report states 5% 
vertebral height loss. The percentage vertebral body height does not meet the criteria for kyphoplasty. 
Therefore, this request is not 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T12 kyphoplasty with guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for February 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed with the incorrect place of service (POS). 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with an incorrect POS code 
of 23 for an emergency department; however, the file shows that the services were rendered while the enrollee was under inpatient status. Therefore, we decided that the Plan does not have to pay for procedure code 99239 
billed for February 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 4, 2022, to 
September 5, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of diagnosis code A41.9. 
 
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 A41.9. 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 submitted records do not support the billing of diagnosis code A41.9. Our physician reviewer found the 
enrollee presented with a leaking catheter and transient chest pain.  He was treated for a leaking catheter and a 
urinary tract infection (UTI). While the enrollee appears to have low blood pressure at baseline, there is no 
evidence of hypoperfusion or organ failure.  As such, a diagnosis of sepsis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 4, 2022, to September 5, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99232 billed for dates of service January 23, 2023, to 
January 24, 2023. 
 
You asked the Plan to pay for code 99232. You say that there is no specific diagnosis that has to be billed as 
primary. The Plan denied your request. The Plan says you billed these services with an inappropriate pair of 
diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of R06.00 and J96.01. Code J96.01 is an Excludes1 code 
under code R06.00, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99232 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99232 billed for dates of service January 23, 2023, to January 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9501 billed for date of service June 1, 2022, 
to June 6, 2022. 
 
You asked the Plan to pay for procedure code S9501. You say that other claims for this patient have been paid. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9501 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9501 billed for date of service June 1, 2022, to June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions - four 
or more teeth or tooth spaces, per quadrant (D7320). 
 
You asked the Plan to pre-approve the alveoloplasty. You say that having this surgery is essential to your 
health. You also say that due to the unevenness of your jaws, you cant chew well which causes digestion 
issues.  The Plan denied your request. The Plan says you do not have benefits for the alveoloplasty service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve 
alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN. You say that IDPN has been formulated to meet the enrollee's 
specific needs. The Plan denied your request. The Plan says the enrollee does not have a malabsorption 
problem nor permanent impairment. 
 
The Plan follows Medicare rules. Medicare rules state that parenteral nutrition may be considered medically 
necessary under certain conditions when enteral nutrition has been ruled out. 
 
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 IDPN. Our reviewer says that the 
enrollee does not meet criteria for IDPN. Our physician reviewer found the provided documentation describes 
the enrollee as tolerating an oral diet. There is no evidence to show the enrollee has a permanent impairment of 
the gastrointestinal tract to absorb nutrients to justify parenteral nutrition support. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intradialytic parenteral nutrition (IDPN).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the enrollee is recommended a 
heart monitor to rule out atrial fibrillation. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for approval. 
 
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 an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of atrial fibrillation. At issue is whether the 
requested authorization for placement of an ILR is medically appropriate and necessary. There is no 
documentation provided to suggest a history of unexplained syncope or any other apparent indication for an 
ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in 
this enrollees clinical management. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the soft tissues of 
the neck.  
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your doctor must provide results of either an endoscopy or a laryngoscopy 
that supports further imaging.  
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the enrollee feels like a knot in their throat 
when swallowing. The enrollee has not had a swallowing study, EGD or laryngoscopy. Without one of these 
studies the medical necessity of the requested CT of the neck without contrast has not been established in the 
records provided. 
 
 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the soft tissues of the neck.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 11, 2022, to 
October 8, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe this denial is not appropriate. 
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 August 11, 2022. The NOA was not received by the Plan until January 26, 
2023. 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 home health services provided 
from August 11, 2022, to October 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast prosthesis (L8035). 
 
You asked the Plan to pay for the breast prosthesis. You say that the item should be covered. The Plan denied 
your request. The Plan says this item 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. If an L8035 breast prosthesis is billed, it will be denied as not reasonable and necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of breast prosthesis have not been met. Therefore, we decided that the Plan does not have to pay for 
the breast prosthesis (L8035).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36558, 76937, 77001, and 99152 rendered 
on November 28, 2022. 
 
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 36558: 
 
Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
CPT 77001: 
 
Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or 
removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast 
injections through access site or catheter with related venography radiologic supervision and interpretation, and 
radiographic documentation of final catheter position) (List separately in addition to code for primary 
procedure) 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
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 in this case, the record indicates 
that the enrollee underwent a procedure. The record is insufficient to document the performance of the 
procedure codes for which coverage is sought. The elements of the coverage criteria are not satisfied. 
 
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 36558, 76937, 77001, and 99152 rendered on November 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Neulasta Onpro (J2506). 
 
You asked the Plan to pre-approve Neulasta Onpro. You say that Neulasta Onpro is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says Neulasta Onpro has been prescribed for an off-label, not 
medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta Onpro. Our reviewer says that 
Neulasta Onpro is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Neulasta Onpro is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta Onpro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Neulasta Onpro (J2506).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total disc arthroplasty. 
 
You asked the Plan to pre-approve total disc arthroplasty. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this surgery is considered investigational for the enrollee's condition. 
 
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 total disc arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 3 level total disc surgery is experimental and not approved by the Food & Drug 
Administration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total disc arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve total disc arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the travel allowance and laboratory services provided on 
February 21, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the travel allowance and laboratory services. The Plan denied your request. The 
Plan says the treating provider is not a network provider with the Plan. The Plan also says that these services 
are not urgent or emergent, nor were they approved in advance.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the travel allowance and laboratory services 
provided on February 21, 2023, by an out-of-network (OON) provider.