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

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device and associated 
supplies (K1018 and K1019). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven this service/item is helpful for the treatment of the 
enrollee's health problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient evidence in the literature that this device is effective for the patient. The 
requested K1018 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Cala Trio nerve stimulator device and associated supplies (K1018 and K1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99345 and 99443 rendered on January 16, 
2023 and 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 documentation does not support the level of service reported. 
 
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 99345: 
 
Home visit for the evaluation and management of a new 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 patient is unstable or has developed a significant new problem requiring immediate physician 
attention. Typically, 75 minutes are spent face-to-face with the patient and/or family 
 
CPT 99443: 
 
Telephone evaluation and management service by a physician or other qualified health care professional who 
may report evaluation and management services provided to an established patient, parent, or guardian not 
originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or 
procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion 
 
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 the procedure report does not 
support CPT 99345. The documentation supports an expanded problem focused history; expanded problem 
focused examination; and medical decision making of low complexity. There is a more appropriate code to 
report for the level of care provided. In terms of CPT 99443, the records do not include sufficient 
documentation to support that a medical discussion was performed. 
 
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 99345 and 99443 rendered on January 16, 2023 and February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested orthosis is safe and effective. 
You also say that it has achieved sufficient adoption by the relevant medical community. The Plan denied your 
request. The Plan says the requested orthosis 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 a MyoPro orthosis. Our reviewer says 
that the requested MyoPro orthosis is not considered medically reasonable and necessary in this case. Our 
physician reviewer found he MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for the enrollees condition or in widespread use for the enrollees condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for the enrollee. Therefore, the reviewer found that the orthosis is not medically reasonable or 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 a MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services billed with diagnosis code J96.01 rendered 
from September 1, 2022, to September 6, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have submitted medical records for review. The Plan denied your request. The Plan says that the DRG was 
updated. 
 
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 J96.01. 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 services at issue in this case were supported by the medical records. Our physician 
reviewer found that the documentation does support the billed diagnosis code. The enrollee presented to the 
hospital on 9/1/2022 with acute onset of shortness of breath and hypoxia. The enrollee looked short of breath, 
with a respiratory rate of 26, and SpO2 of 92%-96% on 4 L/min via cannula. He was diagnosed with an acute 
saddle pulmonary embolism, and underwent an emergent EkoSonic Endovascular System (EKOS) procedure. 
The Pulmonary Consultation Note dated 9/2/2022 documents "submassive pulmonary embolism with acute 
hypoxic respiratory failure." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services billed with diagnosis code J96.01 rendered from September 1, 2022, to September 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition services provided from December 12, 
2022, to December 16, 2022 
 
You asked the Plan to pay for the parenteral nutrition services. You say that the reason for the enrollee's 
condition is not due to a clinical malabsorptive state. You say that the enrollee is not a good candidate for a 
tube feeding as food and fluids can be taken by mouth. You say that due to the severity of the enrollee's 
condition, a noninvasive therapy is preferred. You also say that this treatment is medically necessary to 
improve the enrollee's nutritional status. The Plan denied your request. The Plan says the services were not 
medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable 
and necessary when the beneficiary must have (a) a condition involving the small intestine and/or its exocrine 
glands which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine 
which is a motility disorder and impairs the ability of nutrients to be transported through and absorbed by the 
gastrointestinal (GI) system. 
 
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 parenteral nutrition services. Our 
reviewer says that the parenteral nutrition services were not medically necessary. Our physician reviewer found 
the provided documentation indicates the enrollee can take oral nutrition and supplements, is not underweight, 
and has not exhibited permanent impairment by virtue of his moderate hypoalbuminemia. Therefore, the 
reviewer found that the parenteral nutrition services were not medically reasonable or 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 parenteral nutrition services have not been met. Therefore, we decided that 
the Plan does not have to pay for the parenteral nutrition services provided from December 12, 2022, to 
December 16, 2022
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the office visit and laboratory services billed for date 
of service November 29, 2022. 
 
You asked the Plan to waive the deductible for the office visit and laboratory services. You say that the 
services were discontinued and not completed as charged. You say that the charges should be reversed. The 
Plan denied your request. The Plan says that the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan says these services applied toward the deductible. The 
Evidence of Coverage does not list a deductible amount that applies toward office visits or laboratory services. 
It is the burden of the Health Plan to substantiate their decision with evidence. In this case, the decision has not 
been substantiated so we must find in your favor. Therefore, we decided that the Plan has to waive the 
deductible for the office visit and laboratory services billed for date of service November 29, 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. 
 
Your complaint about the services charged being fraudulent is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299), Adcetris (J9042), Doxorubicin (J9000), 
Vinblastine (J9360) and Dacarbazine (J9130).  
You asked the Plan to pre-approve Opdivo, Adcetris, Doxorubicin, Vinblastine and Dacarbazine. You say that  
this is medically necessary. The Plan denied your request. The Plan says that the requested use of the drug 
combination is not supported.  
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 Opdivo, Adcetris, Doxorubicin, 
Vinblastine and Dacarbazine. Our reviewer says that the requested drug combination is not supported. Our 
physician reviewer found the requested drug combination 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 CMS-
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 Opdivo, Adcetris, Doxorubicin, Vinblastine and Dacarbazine have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299), Adcetris (J9042), 
Doxorubicin (J9000), Vinblastine (J9360) and Dacarbazine (J9130).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is needed to manage the enrollee's condition 
and prevent future exacerbations. The Plan denied your request. The Plan says a ventilator is not covered by 
Medicare for this purpose and the needed therapy mode can be provided by a bilevel positive airway pressure 
(BiPAP) machine. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code 
I82.A12 rendered from February 22, 2022, to February 23, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of the DRG adjustment. The Plan denied your request. 
The Plan says the DRG was updated. 
 
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 DRG 299. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the records do not support diagnosis code I82.A12 - acute embolism and thrombosis of the left axillary 
vein - as the primary diagnosis. The documentation supports pulmonary emboli as the primary diagnosis code. 
The records more support DRG 176 (Pulmonary embolism without Major complication or comorbidity).  
 
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 billed with diagnosis code I82.A12 rendered from February 22, 2022, to 
February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mounting hardware, cane options for a recline system, a 
planar interface plate, waterfall armpads, Visco X-Soft, and a single standard elevating footrest for a 
wheelchair. 
 
You asked the Plan to pre-approve wheelchair components. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the denial of authorization for these components is correct. 
 
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 wheelchair components. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the expandable controller includes all necessary mounting hardware, thus the power 
mount bracket hardware (K0108) x2 is not covered. The cane options for recline system (K0108) is included in the tilt and recline system. The medical necessity for the Waterfall armrests is not addressed in the records. 
Also, K0108 is not a correct code for elevating leg rests. K0108. Guide Brackets Hdw x3, K0108, Top: Visco 
X-Soft 1/2", and K0108, Planar Interface Plate, Standard Back Options are unbundled from the already 
approved cushions and are not covered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair components have not been met. Therefore, we decided that the Plan 
does not have to pre-approve mounting hardware, cane options for a recline system, a planar interface plate, 
waterfall armpads, Visco X-Soft, and a single standard elevating footrest for a wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in an LTACH.  
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting.  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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory service coded as 87481,87563, 87640, 
87651, 87653, 87661 and 87798 provided June 21, 2022. 
 
You asked the Plan to pre-approve the laboratory service. You say that enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. The Plan 
denied your request. The Plan says please reconsider this claim and process towards payment based on the 
information provided. 
 
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 laboratory service. 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 hematuria and suspected urinary tract infection (UTI). Polymerase 
chain reaction (PCR) infectious testing was performed and requested. However, PCR testing in a clinical 
situation where UTI is already suspected is not likely to change treatment choice. The standard of care includes 
urinary analysis and culture and there was no documented suggestion that these would be contraindicated for 
this enrollee or how the PCR would be superior and provide a better outcome overall for the enrollee to justify 
this request. Therefore, this request for PCR testing will be considered 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laboratory service coded as 87481,87563, 87640, 87651, 87653, 87661 and 87798 
provided June 21, 2022.