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

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve the accessories. You say that the requested items are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested items 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 pre-approve the accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested electrical accessories are not medically necessary as the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) 
for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90792 and 99223 rendered on February 8, 
2023, to February 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 there is no evidence that anyone 
provided a psychiatric evaluation on 2/8/2023.  Therefore, the billing of CPT 90792 for 2/8/2023 is not 
supported. The documentation appears to show a psychiatric evaluation on 2/9/23, and the physician (MD) cosigned/provided the psychiatric evaluation on 2/10/23. Assuming the CPT 99223 billed for 2/9/2023 is meant 
to be the initial evaluation provided by the nurse practitioner (NP) on 2/9/2023 and co-signed by the MD on 
2/10/2023, the physical examination is not comprehensive.  As such, the billing of CPT 99223 is not supported. 
 
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 90792 and 99223 rendered on February 8, 2023, to February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on June 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit".  
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 code 99223 is 
not supported by the records provided. Our reviewer found that the documentation does not support a 
comprehensive history, comprehensive exam, or medical decision making of high complexity. 
 
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 (99223) provided on June 27, 2022.
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 feel you have a better chance to get better in 
rehabilitation. You say if you went to the skilled nursing facility, you will be there longer than what you feel 
you need to be. The Plan denied your request. The Plan says the IRF services you are requesting 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 your 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve low dose radiation therapy (LDRT) - 2D/3D conformal and 
external beam. 
 
You asked the Plan to pre-approve LDRT. You say that you are appealing the medical necessity denial for 
outpatient radiation therapy because of primary osteoarthritis of the right hand. The Plan denied your request. 
The Plan says that the treatment is investigational, it is not reasonable and 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 LDRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found while radiotherapy is not commonly utilized for arthritis in the United States (US), it is an 
effective treatment for which many US doctors (who would refer for radiation) are unfamiliar. However, it is 
an accepted standard for osteoarthritis that is resistant to less invasive therapies. Notably, two recent 
randomized trials, one for radiotherapy of arthritic conditions of the knee, and the other for radiotherapy of 
arthritic conditions of the hand, showed no significant benefit of radiotherapy for symptom control compared to 
placebo/sham radiation. The radiation oncologist mentions, in the consultation note, that multiple conservative 
measures had been tried and were not successful. Evicore guidelines state: Degenerative skeletal disorders 
radiation therapy may be used for symptomatic degenerative skeletal and joint disorders (i.e. plantar fasciitis, 
trochanteric bursitis) that are refractory to conventional methods. For plantar fasciitis, for example, 1 (Gray) 
Gy per week for 6 weeks was associated with a response rate approaching 80% and durable at 48 weeks. Using 
complex radiation planning, up to 8 fractions is considered appropriate. Radiation for treatment-resistant 
osteoarthritis, based upon published literature and guideline statements (from Germany) would be considered 
to be furnished with accordance of accepted standards of care and therefore the decision is favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LDRT have been met. Therefore, we decided that the Plan has to pre-approve 
low dose radiation therapy (LDRT) - 2D/3D conformal and external beam.  
 
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 Hyalgan supartz. 
 
You asked the Plan to pre-approve Hyalgan supartz . The Plan denied your request. The Plan says Hyalgan 
supartz is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Hyalgan supartz. Our reviewer says that 
Hyalgan supartz is not medically necessary. Our physician reviewer found that the enrollee has knee 
degenerative joint disease and has had previous supartz injections. However, there is no documentation of 
functional relief from the previous injections. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan supartz have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Hyalgan supartz.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service April 3, 
2023.   
You asked the Plan to pay for procedure code 64488. 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 64488 is 1. The MAI value for this code is 3. You billed 2 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 64488 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64488 billed for date of service April 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says an IRF admission is not supported based on 
the records received.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for pulp cap for tooth #19 (D3120) rendered on March 3, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the services denied correctly as they do not meet the clinical requirements to be 
approved. 
 
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. The Plan covers the services 
when the services are medically necessary and reasonable. 
 
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 services. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found that a 
review of the documentation indicates that tooth #19 sustained a fracture of the distolingual cusp. Deep 
recurrent caries was present and excavated close to the pulp. An indirect pulp cap was placed to allow healing 
and to prevent the need of a root canal. This is an accepted procedure which can be effective when there is no 
pulpal exposure as in this case. The documentation provided meets the criteria for coverage for pulp cap 
(D3120) on tooth #19. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
pulp cap for tooth #19 (D3120) rendered on March 3, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (12032, 11602) provided on March 9, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (12032, 11602) is included in the 
global surgery payment for the procedure (17000) provided on February 28, 2023, which has a 10-day global 
period. 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 (12032, 11602) provided on 
March 9, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0427-RW) provided on July 9, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these were ET3 ambulance services, and the 
"W" modifier is appropriate in this case. The Plan denied your request. The Plan says that modifier "W" is an 
invalid destination modifier on ambulance claims. 
 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code A0429-RW is supported in the medical record. Specifically, modifier W is an 
appropriate destination modifier for use with ET3 ambulance claims. Based on this information, we decided 
that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan 
has to pay for ambulance services (A0427-RW) provided on July 9, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service November 
23, 2022.  
 You asked the Plan to pay for procedure code 88321. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service November 23, 2022.
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 fell due to deconditioning and are on high levels 
of oxygen due to chronic obstructive pulmonary disease and emphysema. You say you need assistance for all 
activities when you get out bed and are requesting reconsideration for the denial of an IRF admission.  The 
Plan denied your request. The Plan says your clinical condition does not require an acute rehabilitation 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have medical need for a singe power option (power tilt) included 
with K0858 group 3 heavy duty power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative 
means of managing power drive. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power mobility wheelchair purchased on April 11, 2022, 
from a non-Medicare certified provider. 
 
You asked the Plan to pay for the power mobility wheelchair. You say that you bought the chair after you 
spoke with three different women who told you that the Plan did help with purchases. The Plan denied your 
request. The Plan says you purchased durable medical equipment from a provider who is not contracted 
through Medicare or in the Plan's network. The Plan also says that you were provided with a list of contracted 
providers one month prior to your purchase. 
 
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 pay for the power mobility wheelchair 
purchased on April 11, 2022, from a non-Medicare certified provider.