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

 
We decided that the Plan does not have to pre-approve a knee orthosis (KO), double upright, thigh and calf, 
with adjustable flexion and extension joint (L1852). 
 
You asked the Plan to pre-approve a knee orthosis. You say that you are requesting reconsideration because 
you have trouble walking and you need the brace to get around. The Plan denied your request. The Plan says 
the records do not show a recent injury or surgery on the knee, or findings of an unstable joint on documented 
physical exam. 
 
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 knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation provided does not support the need for a knee orthosis. You have a 
medical history of left knee osteoarthritis. You are noted to have significant degeneration in your medial 
compartment and received a cortisone injection. However, the physical examination does not demonstrate knee 
instability and there is no indication of recent trauma or surgery. The brace is being ordered to primarily 
offload your knee joint, which is not indicated per the guideline policy. Therefore, the requested knee orthosis 
(L1852) is 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 a knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension 
joint (L1852).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says that the electronic connection, harness, and expandable controller cannot be 
covered as they are not medically necessary to control the three approved power options through the joystick 
(drive interface). 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee requires power elevating leg rests for 
positioning of their lower extremities and lower extremity spasticity. The complexity of the enrollee's seating 
and positioning needs necessitates a more complex group 3 power wheelchair base. Our reviewer found that the 
expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base and the three power options via a joystick. Our physician reviewer also found that these 
components are required to operate 3 or more power options on a group 3 power 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 an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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 pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277x80) and physician attendance and supervision of hyperbaric oxygen therapy, 
per session (99183x20). 
 You asked the Plan to pre-approve hyperbaric oxygen therapy (HBOT). You say that you are requesting 
reconsideration because treatment will promote healing and decrease the chance of amputation. The Plan 
denied your request. The Plan says the records do not show that the enrollee has had no measurable signs of 
wound healing. 
 
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 hyperbaric oxygen therapy (HBOT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the record indicates that the enrollee has a diabetic foot ulcer service. 
The record provided does not document a failure to respond to standard wound care as defined by no 
measurable signs of healing for at least 30 consecutive days. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy (HBOT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (G0277x80) and physician attendance and supervision of hyperbaric oxygen therapy, per session 
(99183x20).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage 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 the ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no documentation of at least 50% sustained improvement in pain relief and/or 
improvement in function measured from the enrollee's baseline for at least three months from the previous ESI. 
Therefore, the criteria for coverage have not been met.  
 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4220 billed for date of service July 8, 2022.  
 
You asked the Plan to pay for procedure code A4220. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code A4220 is bundled into payment for code 62370. 
 
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, we have confirmed that code A4220 
is a column two code to column one code 62370 with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code A4220 billed for date of service July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 standard power wheelchair with multiple power option 
(K0861) and additional items and accessories (codes K0040 x2, E2617, E2609, E2377, E2361 x2, E2313, 
E2311, E1028 x4, E1007, E0955, E0954 x1, and E0953 x2). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says that the enrollee does not meet the medical necessity for a 
powered wheelchair. The Plan also says the enrollee's current needs can be met with an appropriately fitted 
manual wheelchair with tilt-in-space, recline, elevated leg rests, and custom seat cushion.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the requested Group 3 power wheelchair and 
additional items and accessories are medically necessary Our physician reviewer found the enrollee is non-
ambulatory and cannot use a cane or walker for mobility. The enrollee cannot functionally propel a manual 
wheelchair due to upper extremity weakness. The enrollee cannot operate a power scooter due to impaired 
sitting balance and upper extremity strength. Our reviewer found that the enrollee requires a power wheelchair 
for mobility and accomplishing their daily activities. The enrollee cannot perform pressure relief independently 
due to upper extremity weakness and requires a power wheelchair with power tilt and recline for adequate 
pressure relief and positioning. The enrollee requires power elevating leg rests for positioning of their lower 
extremities and lower extremity spasticity and edema. Our physician reviewer also found that the complexity of 
the enrollee's seating and positioning needs necessitates a more complex Group 3 power wheelchair base. 
 
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 Group 3 standard power wheelchair and additional items and accessories have 
been met. Therefore, we decided that the Plan has to pre-approve a Group 3 standard power wheelchair with 
multiple power option (K0861) and additional items and accessories (codes K0040 x2, E2617, E2609, E2377, 
E2361 x2, E2313, E2311, E1028 x4, E1007, E0955, E0954 x1, and E0953 x2).  
 
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 the drug testing services (G0481) provided on May 5, 2023. 
 
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 G0481 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed". 
 
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 G0481 is 
not supported by the records provided. Our reviewer found that 7 drugs were tested in this case, therefore, 
testing for 8-14 drug classes 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 the drug testing services (G0481) provided on May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 13, 2023, and billed with codes 87801, 87150, 87481, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on June 13, 2023, and billed with codes 87801, 87150, 87481, and 87798.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 5, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you have submitted a corrected claim. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 1, 2023. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on February 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hernia repair with an anti-reflux procedure called 
Toupet fundoplication. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of objective 
measures of your reflux-related symptoms. The notes suggest a further workup is being completed with Bravo 
pH testing, but results are not provided. The services are not reasonable or medically necessary based on the 
submitted records.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hernia repair with an anti-reflux procedure called Toupet fundoplication.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (28470) provided on May 5, 2023. 
 
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 28470 is "Closed treatment of metatarsal fracture; 
without manipulation, each". 
 
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 28470 is 
not supported by the records provided. Our reviewer found that the medical record includes documentation to 
support metatarsal fracture, however treatment of the fracture was not documented, and therefore cannot be verified. 
 
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 (28470) provided on May 5, 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 reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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. You do not require 
rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, or tracheostomy 
management. You have had a mild decline from your baseline level of function and may benefit from 
occupational and physical therapies as well as supervision and assistance, but you do not require the intensity 
of therapies provided in an acute inpatient rehabilitation facility.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that you 
are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the vaccine is 
not covered under your health contract.  
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for you to 
continue receiving care. The Plan denied your request. The Plan says you have exhausted your benefit for the 
period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 8, 2023, through 
October 28, 2023. The Plan has covered 100 days of SNF care. 
 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral magnetic resonance imaging (MRI) of the 
breast without and with contrast material. 
 
You asked the Plan to pre-approve the MRI of the breast. You say that the services are medically necessary 
because you have had weeks of pain after you had a mammogram. The Plan denied your request. The Plan says 
you do not meet the criteria for approval. 
 The Plan follows Medicare rules. Medicare rules say that services that are medically necessary are 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 MRI of the breast. Our reviewer 
says that the MRI is not medically necessary. Our physician reviewer found the record does not indicate that 
you have had a clinical scenario enumerated as one for which coverage is available under the rules. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 MRI of the breast have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bilateral magnetic resonance imaging (MRI) of the breast without and with 
contrast material.