Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92960 billed for date of service September 
24, 2022. 
 
You asked the Plan to pay for procedure code 92960. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 92960 is bundled into payment for 
code 99291. 
 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 92960 
is a column II code to column I code 99291. 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 92960 billed for date of service September 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) at L2-L3. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been 50% sustained improvement in pain relief from the first injection. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the request for a series of injections is not supported by the literature. There are other evidence-
based treatments for this patient. The requested procedures are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) at L2-L3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85014, 85018, 85049, 80048, 85027) 
provided on February 8, 2021. 
 
You asked the Plan to pay for laboratory services. You say that if this claim was untimely, it was outside the 
control of the provider. The Plan denied your request. The Plan says this claim was not submitted timely and 
therefore cannot be paid. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for laboratory services was not filed until August 17, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for laboratory services (85014, 85018, 85049, 80048, 85027) 
provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that the patient's physician ordered these lab services, 
so they should be covered. 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.  
 
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 POS code 11, 
indicating that the sample was taken in an office setting. The records do not support that the sample was taken in an office setting. Rather, the records show that the sample was taken at an assisted living facility setting, 
which would be POS 13. Therefore, we decided that the Plan does not have to pay for lab services provided on 
April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary/genetic breast cancer testing (81432, 81433) 
provided on August 22, 2022. 
 
You asked the Plan to pay for genetic breast cancer testing. You say that this testing was necessary because you 
have a family history of breast cancer. The Plan denied your request. The Plan says the criteria for coverage of 
this testing are not met in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that a patient must have any cancer diagnosis in order to qualify for 
hereditary cancer testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic breast cancer testing have not been met. Specifically, the genetic cancer testing in this case 
was provided to a person without a cancer diagnosis. Genetic screening for cancer due to family history is not a 
covered benefit under Medicare. Therefore, we decided that the Plan does not have to pay for 
hereditary/genetic breast cancer testing (81432, 81433) provided on August 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are needed for 
continued care. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry (88188) provided on April 18, 2022. 
 
You asked the Plan to pay for flow cytometry. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the services at issue have not been documented to be 
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 pay for flow cytometry. Our reviewer says that the 
services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that, per the documentation, the enrollee's history shows blastic plasmacytoid dendritic cell neoplasm 
involving skin and cerebrospinal fluid, status post stem cell transplant on August 10, 2021. The records 
received included only a bone marrow report. There is no additional history or records to determine the medical 
necessity of the services at issue. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flow cytometry have not been met. Therefore, we decided that the Plan does not 
have to pay for flow cytometry (88188) provided on April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has a diagnosis of severe chronic obstructive pulmonary disease (COPD) as well has 
obstructive sleep apnea. There is no documentation of chronic carbon dioxide (CO2) retention with an arterial 
blood gas done while stable. Therefore, the enrollee does not meet Medicare criteria for a ventilatory assist 
device. If the enrollee does have chronic CO2 retention, may benefit from bilevel positive airway pressure (BiPAP) with average volume assured pressure support (AVAPS). Medicare does not cover a home ventilator 
when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of implantation of the wireless pulmonary 
artery pressure monitoring system (CardioMEMS) for management of CHF in this patient. 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 patients 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy with ultrasonic guidance. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily imaging is neither necessary nor useful when treating with electron beam, 
superficial radiotherapy, or skin surface brachytherapy. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. Usually 
image-guided radiation therapy (IGRT) is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to this patient for which the target lesion 
can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for 
IGRT unless deep structures are being treated. Billing for daily IGRT which would not be furnished in 
accordance with accepted standards of medical practice. 
 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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiation therapy with ultrasonic guidance.
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 interdisciplinary care and daily 
physician oversight. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
IRF services do not meet the requirements for approval. 
 
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 enrollee is not medically ready with gout and does not need a physical medicine and rehabilitation physician's supervision three times a week in an IRF. There are no acute 
rehabilitation nursing needs identified or documented. At the current level of functional mobility and activities 
of daily living, it is unlikely the enrollee will make a significant functional improvement in a reasonable period 
of time in an IRF, and the enrollee does not need intensive therapies consisting of at least three hours of therapy 
per day at least five days per week with multidisciplinary approach in an IRF. The documentation does not 
support necessity for admission to an IRF due to lack of medical or rehab progress and acute rehabilitation 
nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's 
rehab needs can be provided in a lower intensity and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a group 2 power wheelchair. 
 
You asked the Plan to pay for the power wheelchair. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the power wheelchair. Our reviewer says 
that the requested group 2 power wheelchair is not medically reasonable and necessary. Our physician reviewer 
found that the documentation indicates the requested PWC is intended for use only in the community. There is 
no indication the enrollee is unable to continue to use a power scooter in the home. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pay for a group 2 power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interpretation of the arterial duplex scan provided on July 1, 
2022. 
 
You asked the Plan to pay for duplex scan interpretation. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the services were billed with the wrong place of 
service code. 
 
The Plan must follow Medicare rules. Medicare rules say that that many of the diagnostic services, including 
radiology services, provided by physicians/practitioners contain both a technical component (TC) and a 
professional component (PC). Often, the PC and TC of diagnostic services are furnished in different settings. 
As a general policy, the Place of Service (POS) code assigned by the physician/practitioner for the PC of a 
diagnostic service shall be the setting in which the beneficiary received the TC service. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Section 150 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient services have not been met. The Plan has provided evidence showing that the enrollee 
was an inpatient on the date of service at issue. This claim was billed with an outpatient hospital place of 
service code. This means that the PC has been billed incorrectly billed with a different place of service from the 
TC service. Therefore, we decided that the Plan does not have to pay for interpretation of the arterial duplex 
scan provided on July 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93307 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for procedure code 93307. You say that this procedure is separately payable. The 
Plan denied your request. The Plan says payment for code 93307 is bundled into payment for code 93306. 
 
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 93307 
is a column II code to column I code 93306 with a modifier indicator of 0. The column II 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 93307 billed for date of service September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on August 19, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided to the 
patient for use during surgery to prevent deep vein thrombosis. The Plan denied your request. The Plan says 
this device is not covered for this purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for prevention 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 a pneumatic compression device provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 76000 and 93284 provided to the enrollee on August 
30, 2022, and August 31, 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 that the denied codes cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service. 
 
The definition of the denied codes is: 
 
CPT 76000: 
 
Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time 
 
CPT 93284: 
 
Programming device evaluation (in person) with iterative adjustment of the implantable device to test the 
function of the device and select optimal permanent programmed values with analysis, review and report by a 
physician or other qualified health care professional; multiple lead transvenous implantable defibrillator system 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
medical records support the use of these codes. The procedures represented by the codes were separately 
identifiable from CPT 33235, as there was implantation of another device that these procedures were pertaining 
to. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 76000 and 93284 provided to the enrollee on August 30, 2022, and August 31, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.