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

 
We decided that the Plan does not have to pre-approve an ultraviolet light therapy system (E0691). 
 
You asked the Plan to pre-approve an ultraviolet light therapy system. You say that please find the attached 
documents for review. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
the requested ultraviolet light therapy system. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The record does not show a diagnosis of psoriasis or intractable psoriasis, as there is no indication the enrollee has failed other treatments for psoriasis. Based on this 
information, we decided that Medicare rules for coverage of an ultraviolet light therapy system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet light therapy system 
(E0691).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01630) provided on June 16, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 76 units of CPT code 01630 are not supported in the medical record. Based on this information, 
we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we 
decided that the Plan does not have to pay for anesthesia services (01630) provided on June 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00142 for date of service May 26, 2023. 
 
You asked the Plan to pay for procedure code 00142. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT code 00142 are not payable as billed. Specifically, this service was not billed with one of the 
appropriate modifiers (AA, AD, G8, G9, QK, QS, QY, or GC). Based on this information, we decided that 
Medicare rules for coverage of procedure code 00142 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 00142 for date of service May 26, 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 need this care to regain strength. The Plan 
denied your request. The Plan says medical records do not support the need for an IRF admission and, your 
needs can be safely provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not require 
IRF care with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be safely 
provided in an alternate 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services performed on February 3, 2023, coded 
as 74240, 74230, 72040, 70100, 70310, and 71045. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because they were medically necessary and are supported in the documentation. The Plan denied your 
request. The Plan says the radiology services are denied because they were billed with an inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS.  
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 72040, 70100, 70310, and 71045 were billed with POS 11, 
indicating an office setting. However, documentation shows the radiology services were performed in a mobile 
setting. There is no evidence the services were provided in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services performed on February 3, 2023, coded as 74240, 
74230, 72040, 70100, 70310, and 71045.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical traction device (E0849) provided on June 8, 2023. 
 
You asked the Plan to pay for a cervical traction device. You say that this is supported in the records. The Plan 
denied your request. The Plan says the records do not show the criteria have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that cervical traction devices described by code 
E0849 are only covered if  the beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and 
has received treatment for the TMJ condition; the beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a chin halter is unable to be utilized; or, the treating practitioner orders 
and/or documents the medical necessity for greater than 20 pounds of cervical traction in the home setting. 
 
We looked at the file and Medicare rules. The submitted records do not document that the enrollee had a 
covered condition. Based on this information, we decided that Medicare rules for coverage of a cervical 
traction device have not been met. Therefore, we decided that the Plan does not have to pay for a cervical 
traction device (E0849) provided on June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 and F5 hypercoagulable panel gene analysis (81240, 
81241). 
 
You asked the Plan to pre-approve the genetic testing. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says per the Medicare guidelines, F2 and 
F5 gene analysis (codes 81240 and 81241) is specifically excluded from coverage as it is unlikely to impact 
therapeutic decision-making in the clinical management of members and 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 looked at the file and Medicare rules. These codes are listed under Group 3 Tier 1 Non-covered codes. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve F2 and F5 hypercoagulable panel gene 
analysis (81240, 81241).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 31625 & 31624 provided on June 28, 2023. 
 
You asked the Plan to pay for procedure codes 31625 & 31624. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the records do not support the billed codes. 
 
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 codes 31625, & 31624 are rigid or flexible bronchoscopy, 
including fluoroscopic guidance, when performed, with bronchial or endobronchial biopsy(s) and rigid or 
flexible bronchoscopy, including fluoroscopic guidance, when performed, with bronchial alveolar lavage. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 31625 & 31624. Our reviewer says that the records do not support the billed services. Our reviewer found code 31625 is inclusive to code 31641 which 
was also billed. Records do not support a distinct and separate service. Code 31624 is not supported by the 
medical records submitted. The operative report did not include documentation of this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 31625 & 31624 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 31625 & 31624 provided on June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (T4526). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the requested items are a necessity for 
your care. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4526).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair repairs (K0108, K0739). 
 
You asked the Plan to pay for the wheelchair repairs. You say that this service is medically necessary. The Plan 
denied your request. The Plan says insufficient information was provided to support this request. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the wheelchair repairs have been met. 
No detailed work orders were provided for the requested repairs. Therefore, we decided that the Plan does not 
have to pay for wheelchair repairs (K0108, K0739).
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 have medical complexities that requires 
physician oversight, frequent monitoring and intervention through physician face to face visits at least 3 times 
per week. The Plan denied your request. The Plan says an 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 The complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for peritonitis and end stage renal disease. Medical problems are stable. There are no complex nursing 
or rehabilitation needs.  
 
The patient 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 
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 this patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that you would like to request reconsideration of the 
denied PET scan and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the criteria for a PET scan have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET scan. Our physician reviewer 
found given that the likely diagnosis on radiology comment is that it represents a post-inflammatory nodule, 
and close follow-up is recommended with a computed tomography (CT) scan on the report.  
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 needs this care to regain maximum 
function. The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for an 
IRF admission.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
11, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 for date of 
service July 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with code 81479 for date of service July 29, 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 IRF is necessary in order to regain physical mobility 
so the enrollee will maintain their quality of life. The Plan denied your request. The Plan says that the enrollee 
does not meet all of the IRF requirements.  
 
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 the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. 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.  
 
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 custom ramp. 
 
You asked the Plan to pre-approve a custom ramp. You say that your step is going into the grass and need an L 
shaped ramp. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a custom ramp.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve semi-electric hospital bed with any type side rails, with mattress 
(E0260). 
 
You asked the Plan to pre-approve the hospital bed. You say that you are appealing the denial of the semi 
electric hospital bed because of the enrollee's chronic obstructive pulmonary disease with acute lower 
respiratory infection. The Plan denied your request. The Plan says that the enrollee does not meet the coverage 
criteria for the requested semi electric hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that 
the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is noted to have weakness and a history of stroke. The enrollee is dependent for 
mobility and performing transfers as well as most of their daily activities, including dressing and toileting. The 
enrollee is not noted to have skin breakdown but does not have the ability to independently perform positional 
changes while in bed. The enrollees medical conditions and level of function would support a semi-electric 
hospital bed and is at risk for skin breakdown. Therefore, the requested semi-electric hospital bed (E0260) is 
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 hospital bed have been met. Therefore, we decided that the Plan has to pre-
approve semi-electric hospital bed with any type side rails, with mattress (E0260).  
 
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.