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

 
We decided that the Plan does not have to pay for the services (12042, 11423) provided on May 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
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 12042 is "Repair, intermediate, wounds of neck, hands, 
feet and/or external genitalia; 2.6 cm to 7.5 cm". The CPT Code Manual definition of codee 11423 is 
"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, 
genitalia; excised diameter 2.1 to 3.0 cm". 
 
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 codes 12042 
and 11423 is not supported by the records provided. Our reviewer found that the medical records do not include 
sufficient documentation to validate that a repair, intermediate, wounds of neck, hands, feet and/or external 
genitalia; 2.6 cm to 7.5 cm, was performed on May 27, 2022, therefore this service cannot be verified. The medical records provided do not include sufficient documentation to validate that an excision, benign lesion 
including margins, except skin tags (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised 
diameter 2.1 to 3.0 cm, was performed on May 27, 2022, therefore this service 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 (12042, 11423) provided on May 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76641) provided on September 20, 
2022. 
 
You asked the Plan to pay for the breast ultrasound. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the breast ultrasound have not been met. CPT code 76641 26 LT 
and 76641 26 RT is not billed in accordance with Medicare National Correct Coding Initiative Policy. 
Medically Unlikely Edits (MUE). This is not a medical necessity denial. CPT code 76642 26 LT and 76642 26 
RT has an MUE value of 1, but billed 2 units. Therefore, we decided that the Plan does not have to pay for the 
breast ultrasound (76641) provided on September 20, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the services (60512) provided on February 9, 2022. 
 
You asked the Plan to pay for the services. You say that fasdfads The Plan denied your request. The Plan says 
that this code is inclusive to code 60500. 
 
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 60512 is "Parathyroid autotransplantation (List separately in addition to code for primary procedure)". 
 
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 60512 is 
supported by the records provided. Our reviewer found that the medical records provided indicate a 
Parathyroidectomy or exploration of parathyroid(s) (CPT 60500) was performed as the primary procedure on 
February 9, 2022. CPT 60512 is an add-on code, not a (Separate Procedure) CPT code, and per CPT Manual 
guidance, CPT 60512 can be used in conjunction with CPT 60500. The medical records submitted validate that 
CPT 60512 was performed in addition to primary procedure 60500 and is eligible for billing and 
reimbursement consideration. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services (60512) provided on February 9, 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.
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 May 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. 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 May 3, 
2022.
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 meets criteria for admission after a hip 
fracture. The Plan denied your request. The Plan says the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF), home with home 
health services, or home with outpatient therapy. 
 
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 enrollee was admitted for surgical repair of a hip fracture. The enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 
is a column II code to column I code 99233. 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 99232 billed for date of service June 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 99284. The Plan denied your request. The Plan says payment for 
code 99284 is bundled into payment for code 99285. 
 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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service August 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia service (01402-QZ) provided on June 9, 2022. 
 
You asked the Plan to pay for anesthesia service. You say that you are appealing this denial. The Plan denied 
your request. The Plan says that this code was not billed with an appropriate modifier to identify a 
distinct/separate operative session. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit any medical records or documented attempts to obtain 
medical records related to the billed code. The Plan also did not submit evidence showing that this claim is a 
duplicate of an already paid code. Without this information, the Plan has not shown that its decision to deny 
payment of this service is correct or justified. Therefore, we decided that the Plan has to pay for anesthesia 
service (01402-QZ) provided on June 9, 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88381, and 88360 billed for 
date of service April 1, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88381, and 88360. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says these codes are included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88381, 
and 88360. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT codes 88341, 
88342, 88381, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88381, and 88360 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 88341, 88342, 88381, and 88360 billed for date of service April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary in this case. Our physician reviewer 
found that the enrollee is a 75-year-old male with chronic low back pain with radiation to his right lower 
extremity. The pain is exacerbated with walking, sitting, and standing. The enrollee has been treated with 
medical therapy including opiates, physical therapy, acupuncture and chiropractic therapy. The enrollee had 
L4-L5 and L5-S1 epidural steroid injections (ESIs) on September 22, 2022 that provided 60-70% 
improvement. In this case, it has not been 3 months since the last injections. The review has determined that the 
requested epidural steroid injections do not meet the Medicare LCD coverage criteria. 
 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement tooth #'s 30 and 
31 (D6104). 
 
You asked the Plan to pre-approve the bone graft at time of implant placement tooth #'s 30 and 31 (D6104). 
You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
graft at time of implant placement tooth #'s 30 and 31 (D6104).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81432 and 81433) provided on May 
18, 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 LCD 38972 criteria is not met as the requested test is not an approved test with 
Palmetto GBA and has not been evaluated by the MolDx Programs technical assessment process. The Plan 
states the request represents apparent claim unbundling and is not allowed by CMS. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. LCD 38972 criteria is 
not met as the requested test is not an approved test with the Medicare contractor and has not been evaluated by 
the MolDx Programs technical assessment process. In addition, the request represents apparent claim 
unbundling and is not allowed by CMS. This request for payment for multiple CPTs in this case are denied as 
per Medicare guidelines, LCA 57880 it is not appropriate to bill individual CPT codes for a single panel. If a 
laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of 
the same panel. A panel constitutes a single procedural service, so 1 HCPCS codes must be submitted for the 
panel. Medicare says if a single procedure is performed, only one code with one unit of service may be reported 
for the procedure. Therefore, we decided that the Plan does not have to pay for the laboratory services (81432 
and 81433) provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve an over-bed table. You say that you need this item. The Plan denied your 
request. The Plan says this item does not primarily serve a medical purpose. 
 
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 an over-bed table (E0274).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for an office visit provided on August 25, 2022.  
 
You asked the Plan to waive the deductible for an office visit. You say that this was an annual wellness visit. 
The Plan denied your request. The Plan says that the cost sharing was applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not include a summary of your deductible with the case file. 
Without this information we are unable to determine if it is appropriate to apply this amount to your deductible. 
Therefore, we decided that the Plan has to waive the deductible for an office visit provided on August 25, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Volara chest therapy system and supplies (E1399). 
 
You asked the Plan to pre-approve Volara chest therapy system and supplies. You say that you disagree with 
the denial and medical records have been submitted. The Plan denied your request. The Plan says the requested 
device for the treatment of cystic fibrosis and other respiratory disorders, is experimental and investigational 
because there is insufficient evidence supporting its effectiveness. 
 
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 Volara chest therapy system and 
supplies. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has spinal muscular atrophy with thoracic 
restrictive disease due to dextroscoliosis. There have been repeated hospitalizations over the past 2 years for 
respiratory issues, and in June of 2021, required treatment with BiPAP for acute on chronic hypercarbic 
respiratory failure. The enrollee is not currently on BiPAP as an outpatient. There is no diagnosis of 
bronchiectasis or cystic fibrosis. The enrollee has a chronic cough, but there is little documentation of sputum 
production or difficulty raising secretions.  The Volara system combines 3 treatments, nebulization, airflow 
oscillation, and positive end-expiratory pressure. It has not been shown, in high-quality clinical studies, to be 
safe and beneficial in the treatment of any lung disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Volara chest therapy system and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Volara chest therapy system and supplies (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 heavy duty, multiple 
power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0843) and accessories 
(E2377, E2313, E1028x4, E1007, E1012, K0108x3, E2311). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
is medically necessary. The Plan denied your request. The Plan says the requested chair is requested for the 
convenience of leg elevation when the enrollee is actually in the chair. The enrollee is not currently confined to 
the chair and is not indicated to spend prolonged periods in the PWC. He is definitively demonstrated to be 
able to weight shift while in the chair and additional protection could be offered if desired by the addition of a 
pressure relieving cushion to his current chair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
 
 
 
 The file shows that the enrollee was approved for a group 2 power wheelchair a year ago. This approved 
wheelchair serves the same purpose as the requested power wheelchair and accessories. The resource use of 
providing another power wheelchair when he has a relatively new device for the original purpose of self-
mobility cannot be justified in terms of cost/benefit. Therefore, we decided that the Plan does not have to pre-
approve a power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight 
capacity 301 to 450 pounds (K0843) and accessories (E2377, E2313, E1028x4, E1007, E1012, K0108x3, 
E2311).