Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0018U, 0245U) provided on July 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
were not provided on the billed date of service. 
 
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 payment for CPT codes 0018U and 0245U is not supported in the medical record. Specifically, the 
records provided do not show that the services were provided on the billed date of service. The records show 
that the billed services were provided on July 8, 2022. 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 lab services (0018U, 0245U) provided on July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and related 
services (A9901) provided from December 8, 2022, to December 21, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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. 
 
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, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) 
and related services (A9901) provided from December 8, 2022, to December 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee is experiencing discomfort. 
The Plan denied your request. The Plan says the enrollee's condition does not show objective clinical 
improvement with respect to function or reduction of complexity of the condition after period of skilled 
therapy.   
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has persistent pain which has responded some and has a 
home exercise program and is functional. There is no indication for continued input from a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation (PVA- 
kyphoplasty) of lumbar vertebral body L3 and L5 (22514 and 22515). 
 
You asked the Plan to pre-approve the service. You say that  the surgery is medically necessary.  The Plan 
denied your request. The Plan says the kyphoplasty is not medically necessary. The Plan says there is 
insufficient documentation to exclude contraindications and insufficient documentation of reevaluation after a 
trial of non-surgical management.  
 
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 service. Our physician reviewer 
found there is no trial of a back brace; therefore, the services are 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous vertebral augmentation (PVA- kyphoplasty) of lumbar vertebral body L3 
and L5 (22514 and 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on February 15, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you paid for this service out of pocket, 
and you are requesting reconsideration of the denial. The Plan denied your request. The Plan says compression 
stockings are not covered as dressings and do not meet the definition of durable medical equipment.  
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and retractable or removable mounting hardware for joystick (E1028). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and retractable or 
removable mounting hardware for joystick. You say that when three or more power seating 
functions/actuators/motors are provided, one unit of E2311, one unit of E2377, and one unit of E2313 are 
allowed. The Plan denied your request. The Plan says although there are three requested power options (tilt, 
recline and elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 electronic connection, harness, 
expandable controller, and retractable or removable mounting hardware for joystick. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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. There is not a medical need for the upgraded electronics. Our reviewer also found that as it is 
not medically necessary to control the power wheelchairs power options through a joystick, the retractable or 
removable mounting hardware for joystick (E1028) 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 an electronic connection, harness, expandable controller, and retractable or 
removable mounting hardware for joystick have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311), harness (E2313), expandable controller (E2377), and 
retractable or removable mounting hardware for joystick (E1028).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee needs to continue with skilled 
physical therapy to increase mobility and posture. The Plan denied your request. The Plan says there is no 
clinical evidence to support the medical necessity of this examination or that the enrollee meets Medicare 
criteria for continued therapy services.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program.  There is no documentation of a recent injury or decline 
in function. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that additional visits are medically necessary 
for the enrollee. The Plan denied your request. The Plan says there is no clinical evidence to support the 
medical necessity of this examination or that the enrollee meets Medicare criteria for continued therapy 
services.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the documentation indicates the enrollee can perform a home exercise 
program. There is no indication that the enrollee requires additional formal therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an ultralightweight wheelchair. You say that you have an amputated leg and 
are not able to get around without a wheelchair. You are unable to use a prosthetic because the arthritis is too 
severe, and it is detrimental to your health to not have the requested chair. The Plan denied your request. The 
Plan says you requested a wheelchair from an OON durable medical equipment (DME) company and the 
device is available with an in-network DME provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ultralightweight wheelchair (K0005) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuromuscular stimulator, electronic shock unit 
(E0745). 
 
You asked the Plan to pre-approve a neuromuscular stimulator. You say that the enrollee was using a friends 
device daily and it helped with her low back pain. The Plan denied your request. The Plan says the requested 
device does not meet the definition of medical necessity. 
 
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 neuromuscular stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found an electronic shock unit stimulator is experimental and investigational for 
back pain. More research is needed to show efficacy. 
 
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 neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a neuromuscular stimulator, electronic shock unit (E0745).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the member requires additional skilled rehab services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) and a tangential biopsy of skin 
(11102). 
 
You asked the Plan to pre-approve an office visit and a skin biopsy. You say that you have a spot on your face 
that is concerning. You would like a skin check with the requested dermatologist, rather than your primary care 
physician (PCP). The Plan denied your request. The Plan says you do not meet criteria for approval to see a 
dermatologist at this time. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of an office visit and a skin biopsy have not been met. Specifically, there is no documentation for any 
skin lesions suspicious for skin cancer. Your PCP can perform the skin assessment on you and if there are any 
positive findings that would require an evaluation with a dermatologist, then the PCP will recommend a 
dermatology consult. There is no medical necessity for a specialty referral to see a dermatologist at this time. 
Therefore, we decided that the Plan does not have to pre-approve an office visit (99203) and a tangential biopsy 
of skin (11102).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are not medically 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary 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 a CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on March 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service April 7, 2023, to 
April 8, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
 We find that CPT code 99233 is not supported in the medical record. Specifically, the documentation did not 
include the total time spent on the services for these dates of service. Without a total of time of 50 minutes or 
more, the code billed cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99233 for date of service April 7, 2023, to April 8, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Stereotactic Radiosurgery (SRS) (77370, 77372). 
 
You asked the Plan to pre-approve SRS. You say that the requested treatment is medically necessary and is 
preferred to whole brain irradiation. The Plan denied your request. The Plan says that the enrollee does not 
meet criteria for approval of SRS. 
 
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 SRS. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found SRS is an accepted standard of care for limited metastases from small cell lung cancer.  
The American Society for Radiation Oncology (ASTRO) model policy for radiosurgery lists no restrictions on 
SRS based upon primary cancer type or number of lesions, or prior treatment (i.e., having undergone prior 
SRS) but rather emphasizes the need of SRS in enrollees with good performance status, and who are expected 
to have a reasonably long-life expectancy warranting treatment. Given that the treatment of limited brain 
metastases with SRS in an enrollee with small cell lung cancer with good performance status is in accordance 
with accepted standard practice (First-line Radiosurgery for Small-Cell Lung Cancer) FIRE-SCLC conclusions 
and National Comprehensive Cancer Network (NCCN) guidelines). The reviewer believes that the treatment 
can be considered within accordance of accepted standards of medical practice and therefore 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 SRS have been met. Therefore, we decided that the Plan has to pre-approve 
Stereotactic Radiosurgery (SRS) (77370, 77372).  
 
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.