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

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service July 12, 
2022. 
 You asked the Plan to pay for procedure code 87150. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. Additionally, CPT 87481, CPT 87798, CPT 87641, and CPT 
87653 are column 2 codes to the column 1 code 87801 and 87150. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 87150 billed for date of 
service July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the high pressure pneumatic compression device (E0675) 
and segmental gradient pressure pneumatic appliances (E0673 x2) provided on April 11, 2022. 
 
You asked the Plan to pay for the high pressure pneumatic compression device and segmental gradient pressure 
pneumatic appliances. You say that the most effective therapy for the prevention of deep vein thrombosis and 
its related complications during surgery is intermittent pneumatic compression therapy. You also say that 
intermittent pneumatic compression therapy is the industry standard for preventing the costly and potential life-
threatening complications that may arise from deep vein thrombosis. The Plan denied your request. The Plan 
says the denial of the intermittent limb compression device was appropriate. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. Medicare rules also say that if the base PCD is not covered, related accessories 
are 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 high pressure pneumatic compression device (E0675) and segmental gradient pressure pneumatic 
appliances (E0673 x2) provided on April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair chair (E0170) purchased on November 8, 2022. 
 
You asked the Plan to pay for the stair chair. You say that without the stair lift you cannot get to your bedroom, 
and you cannot afford to move to a single-story house. The Plan denied your request. The Plan says this is a 
non-covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for the stair chair (E0170) purchased on November 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that a spinal cord stimulator is medically 
necessary. The Plan denied your request. The Plan says the requested spinal cord stimulator does not meet the 
Medicare coverage guidelines.  
 
The Plan follows Medicare rules.  
 
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 spinal cord stimulator. Our reviewer 
says that the requested spinal cord stimulator is not considered medically necessary in this case. Our physician 
reviewer found Medicare NCD requires that spinal cord stimulator be a late or last procedure. Clearly, you 
have multiple evidence-based therapies available. You have not had a surgical consultation and have not had 
adequate medication trials. You have not had prior injection therapy. You are not a candidate for spinal cord 
stimulator at this time and the request is not medically reasonable and necessary at this time.   
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Mitomycin (J9281). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says that the requested drug or mix of drugs is not supported in the National 
Comprehensive Cancer Network (NCCN) guidelines for the stage of the enrollee's cancer. 
 
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 the medication. Our physician reviewer 
found per Micromedex: Mitomycin pyelocalyceal solution is indicated for the treatment of adults with low-
grade upper tract urothelial cancer. Mitomycin pyelocalyceal instillation resulted in a complete response in 
some patients in the open-label, single-arm OLYMPUS trial in patients with treatment-naive or recurrent 
noninvasive low-grade upper tract urothelial cancer. Per the guidelines of the National Comprehensive Cancer 
Network: Intrapelvic and Intravesical Therapy for Upper Tract Tumors  Primary Therapy Complete or near 
complete endoscopic resection or ablation is recommended prior to mitomycin ureteral gel application, which 
is most suitably indicated for a residual, low-grade, low-volume (515 mm), solitary tumor in the upper urinary 
tract for a patient who is not a candidate for or not seeking nephroureterectomy as a definitive treatment. 
Mitomycin for pyelocaliceal application may be administered via ureteral catheter or a nephrostomy tube. Per 
the guidelines, our physician reviewer found that the requested medication is 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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Mitomycin (J9281).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Apos shoes (T1999). 
 
You asked the Plan to pre-approve Apos shoes. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve Apos 
shoes (T1999).
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's current physical and occupational 
deficits, along with her comorbidities we have determined to require and would benefit from intensive inpatient 
rehabilitation with daily physician visits and examinations, 24-hour rehabilitation, nursing care, intensive 
physical and occupational therapies to optimize mobility and regain the ability to perform activities of daily 
living. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an Inpatient Rehabilitation Facility. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the requested Intracept procedure 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet joint disease or foraminal stenosis. The cause of back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner (E1399). 
 
You asked the Plan to pre-approve a recliner. You say that you disagree with the denial and request 
reconsideration. You need the requested item. The Plan denied your request. The Plan says the requested item 
is not covered under your benefit plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 31 units of procedure code E0562 rendered from December 
12, 2022. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code E0562 (31 units) remains not 
supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider reported rental for a 
humidifier for dates of service 12/12/22 through 1/11/23 and billed 31 units.   This item would be a monthly 
charge, and in this case, 31 units billed 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 31 units of procedure code E0562 rendered from December 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral thigh lift and liposuction. 
 
You asked the Plan to pre-approve a bilateral thigh lift and liposuction. You say that you have excess skin 
following weight loss.  You said that you need surgery to remove this skin because it is affecting your ability to 
walk.  You said that you must wear pants to keep your leg skin in place and walk normally.  You also said that 
the extra skin makes you walk slower and causes chafing. The Plan denied your request. The Plan says the 
requested procedures are not medically necessary and are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only limited reconstructive and cosmetic 
surgeries are covered.  The requested thigh lift and liposuction are not among those reconstructive procedures 
covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a bilateral thigh lift and liposuction have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a bilateral thigh lift and liposuction.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 30, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 4, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chiropractic manipulation (98941), electric stimulation 
(G0283), and mechanical traction therapy (97012). 
 
You asked the Plan to pre-approve the chiropractic services. You say that the diagnosis codes used designate 
subluxation. The Plan denied your request. The Plan says that the chiropractic manipulation is not medically 
necessary because the clinical exam did not show signs of subluxation, and that electric stimulation and 
mechanical traction therapy are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
  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 chiropractic manipulation. Our 
reviewer says that the record indicates that the enrollee has lumbago and sciatica. The records provided do not 
document the presence of subluxation either by physical examination or radiographic images. 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 chiropractic manipulation have not been met. The records show that the 
requested electric stimulation and mechanical traction therapy are not manual manipulations of the spine. 
Therefore, we decided that the Plan does not have to pre-approve a chiropractic manipulation (98941), electric 
stimulation (G0283), and mechanical traction therapy (97012).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 11, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub wall rail (E0241). 
 
You asked the Plan to pre-approve a bathtub wall rail. You say that you need the emergency railings approve 
for your bathroom due to your health condition. The Plan denied your request. The Plan says this service is not 
covered by Medicare and is not considered medical. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a bathtub wall rail (E0241).