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

 
We decided that the Plan does not have to pay for procedure codes 99601 and A4305 billed for date of service 
July 1, 2022, to July 24, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and A4305. The Plan denied your request. The Plan says 
the billed codes are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. Medicare rules also say that disposable 
drug delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices 
because they do not meet the Medicare definition of durable medical equipment. 
 
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. We also find that the requested disposable drug 
delivery system (A4305) is not covered per LCA A52507. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 99601 and A4305 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 99601 and A4305 billed for date of service July 1, 2022, to July 
24, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a security deposit for rental, application fee for rental, and 
the purchase of alcohol, wax paper, and storage bags received May 1, 2022, to June 30, 2022. 
 
You asked the Plan to pay for a security deposit for rental, application fee for rental, and the purchase of 
alcohol, wax paper, and storage bags. You say that you need the funds paid because you paid out-of-pocket. 
The Plan denied your request. The Plan says the services/items received are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Personal comfort items are not covered. 
 
We looked at the file and Medicare rules. Security deposits, application fees, and alcohol, wax paper, and 
storage bags are not covered. The items at issue in this appeal do not serve a purpose that is primarily medical 
in nature. These items are available to the general public and would be helpful even to those who are not sick 
or injured. Based on this information, we decided that Medicare rules for coverage of a security deposit for 
rental, application fee for rental, and the purchase of alcohol, wax paper, and storage bags have not been met. 
Therefore, we decided that the Plan does not have to pay for a security deposit for rental, application fee for 
rental, and the purchase of alcohol, wax paper, and storage bags received May 1, 2022, to June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthetic leg and additional components addition, 
endoskeletal system, below knee, flexible protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve the prosthetic leg and additional components the protective covering. You 
say that you will be moving up north and will be exposed to harsh wet conditions. The Plan denied your 
request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
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 protective covering. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee's activities have special needs 
for protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is afforded by a standard cover. 
 
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 protective covering have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the prosthetic leg and additional components addition, endoskeletal system, 
below knee, flexible protective outer surface covering system (L5962).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional home health visits (G0151). 
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. The records do not support the 
need for a skilled physical therapist to make more home visits at this time. The approved additional visits 
should be adequate to complete any further enrollee education and reinforcement of the home exercise 
program. 
 
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 enrollee 
has cognitive impairment and a recent hip fracture. He is able to walk 250 at supervision level and transfer to 
toilet at supervision level. The enrollee is walking at a community level and only requires supervision. In-home 
therapy is not medically necessary per chapter 7. The enrollee is not home bound and does not have 
considerable and taxing effort to leave 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight (8) additional home health visits (G0151).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis, posterior or posterolateral technique, 
single interspace; lumbar (22612), posterior non-segmental instrumentation (22840), laminectomy, facetectomy 
and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], 
single vertebral segment; lumbar (63047), laminectomy, facetectomy and foraminotomy (unilateral or bilateral 
with decompression of spinal cord, cauda equina and/or nerve root[s], single vertebral segment; each additional 
vertebral segment, cervical, thoracic, or lumbar (63048), and an allograft, morselized, or placement of 
osteopromotive material, for spine surgery (20930). 

 You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that enrollees must meet indicated criteria for a lumbar 
fusion.  
 
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 requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has multiple stable lumbar compression fractures and degenerative changes in 
the lumbar spine. There is no evidence of spinal instability. The fractures will heal with bracing and no surgery. 
Surgery is not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an arthrodesis, posterior or posterolateral technique, single interspace; lumbar (22612), 
posterior non-segmental instrumentation (22840), laminectomy, facetectomy and foraminotomy (unilateral or 
bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], single vertebral segment; 
lumbar (63047), laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s], single vertebral segment; each additional vertebral segment, 
cervical, thoracic, or lumbar (63048), and an allograft, morselized, or placement of osteopromotive material, 
for spine surgery (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of sclerosant; single incompetent vein 
(other than telangiectasia) (36470) and an injection of sclerosant; multiple incompetent veins (other than 
telangiectasia), same leg (36471). 
 
You asked the Plan to pre-approve injections. You say that the enrollee has worsening large varicose veins in 
the lower extremities and is requested for Venaseal of the left greater saphenous vein (GSV), Varithena of the 
left medial, anterior and lateral calf tributaries and left lateral thigh tributaries. The Plan denied your request. 
The Plan says the request is not medically necessary because there is no indication that the enrollee has 
symptoms which interfere with daily activities. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not meet guideline criteria for use of this therapy. There is no evidence 
of symptomatic impairment of activities of daily living or of a documented trial of conservative treatment. In 
summary, there is insufficient documentation to support the medical necessity for the requested venous 
sclerotherapy in this enrollee's 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an injection of sclerosant; single incompetent vein (other than telangiectasia) (36470) and an 
injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg (36471).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress echocardiography. 
 
You asked the Plan to pre-approve a stress echocardiography. You say that a stress echocardiography is 
medically necessary. You say that the enrollee had an abnormal electrocardiogram and her stress test showed 
significant artifacts. The Plan denied your request. The Plan says the request is not medically necessary 
because the member is able to exercise and does not have hypertrophic cardiomyopathy (HCM) and a recent 
echo revealed no evidence of any cardiomyopathy. 
 
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 stress echocardiography. Our 
reviewer says that the requested stress echocardiography is not medically necessary in this case. Our physician 
reviewer found that at issue is the medical appropriateness and necessity of carrying out a stress 
echocardiogram in evaluating the enrollee, who has no cardiac symptoms. There is no documentation that the 
electrocardiogram (ECG) shows an uninterpretable pattern. There is no evidence provided that would support 
the need for stress echocardiography. In summary, there is insufficient documentation to support the medical 
necessity for the requested stress echocardiography 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 stress echocardiography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a stress echocardiography.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99285 billed for October 4, 2022.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99285 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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

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 these services. Our reviewer says that procedure code 99285
is not supported. Our reviewer found

We looked at this coder'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 pay for procedure code 99285 billed for October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88368, 88369 and 88377) provided 
on August 29, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the payment for these services is included in the payment for the other services 
provided. 
 
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 laboratory services. Our physician 
reviewer found For CPT 88368, the documentation submitted was reviewed, and does not meet criteria. 
Although this procedure has a modifier indicator 1, laboratory does not support this service as distinct and does 
not overlap usual components of the main service. For CPT 88369, the documentation submitted was reviewed, 
and does not meet criteria. Although this procedure has a modifier indicator 1, laboratory does not support this 
service as distinct and does not overlap usual components of the main service. For CPT 88377, the 
documentation submitted was reviewed, and does not meet criteria. Although this procedure has a modifier 
indicator 1, laboratory does not support this service as distinct and does not overlap usual components of the 
main service. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (88368, 88369 and 88377) provided on August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83550 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 83550. You say that these services are supported as billed. The 
Plan denied your request. The Plan says payment for code 83550 is bundled into payment for code 84466. 
 
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 83550 
is a column II code to column I code 84466 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 83550 billed for date of service March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108), a push handle (K0108x2) and 
custom back extensions (K0108x2). 
 
You asked the Plan to pre-approve manual wheelchair accessories. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says the requested accessories are not 
considered durable medical equipment, as they are not primarily medical in nature and do not meet the 
Medicare criteria for DME. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. The transit system is 
used to transport the wheelchair outside of the home, the push handles are extra handles added on to move the 
wheelchair, and the back extensions are used to adjust the back cushion. These items are 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 transit system (K0108), a push handle (K0108x2) and custom back 
extensions (K0108x2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve MPI. 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 follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary under certain circumstances. 
 
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 MPI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the limited documentation provided does 
not indicate the rationale for this imaging study. A vascular surgery office visit and an echocardiogram report 
are provided for review. There is no evidence provided that would support the need for radionuclide stress 
testing. In summary, there is insufficient documentation to support the medical necessity for the requested 
cardiac stress testing 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 MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging (MPI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of sclerosant; single incompetent vein 
(other than telangiectasia) (36470 - 1 unit) and an injection of sclerosant; multiple incompetent veins (other 
than telangiectasia), same leg (36471 - 2 units). 
 
You asked the Plan to pre-approve injections. You say that the enrollee has chronic venous insufficiency and 
complains of continued lower extremity pain and discomfort alongside her lower extremity edema. She is 
requested for Varithena of the left medial calf. The Plan denied your request. The Plan says medical records 
show that the enrollee has painful swollen varicose veins. She has failed conservative treatment. The medical 
records do not support that the enrollee met the guidelines for this procedure. The doctor requested additional 
treatment without indicating the names of the veins and dates of treatment. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found authorization has been provided for one vessel location, the left tributary, but the provided 
documentation does not meet guideline criteria for use of this therapy elsewhere. In summary, there is 
insufficient documentation to support the medical necessity for the requested venous sclerotherapy beyond the 
already-approved sclerotherapy site in this enrollee's 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an injection of sclerosant; single incompetent vein (other than telangiectasia) (36470 - 1 unit) 
and an injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg (36471 - 2 
units).