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

 
We decided that the Plan does not have to pay for the genetic testing for cardiovascular disease provided on 
November 5, 2021, billed with codes 81286, 81413, 81414, 81442, 81161 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services were not reported correctly as some of the codes 
billed include the services for other codes billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing for cardiovascular disease provided on November 5, 2021, billed with codes 81286, 81413, 81414, 81442, 81161 
and 81479.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on December 28, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204) provided on January 19, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was treated and medically necessary 
services were provided in good faith to provide treatment. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99204) provided on 
January 19, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving the care he needs in the hospital 
where he is now. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve a vacuum pump. You say that the item is not experimental or unproven. The 
pump you currently have has failed and is out of warranty. A new vacuum pump is needed. The Plan denied 
your request. The Plan says this vacuum socket is experimental and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a vacuum pump. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare allows for replacement of a prosthesis or prosthetic component if there is a change in 
the physiological condition of the beneficiary, there is irreparable wear of the device or a part of the device or if 
the condition of the device, or part of the device, requires repairs and the cost of such repairs would be more 
than 60% of the cost of a replacement device, or the part being replaced. In this case, you have a 
malfunctioning socket system. The requested device has not been shown to be superior to other standard 
treatments for your medical condition. 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 vacuum pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume management 
and moisture evacuation system (L5781).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for destruction of malignant lesion (eg, laser surgery, 
electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia (17272) 
provided on May 9, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient surgery. You say that you are proving the medical records and 
strongly believe that the services rendered are a medical necessity and eligible for payment. The Plan denied 
your request. The Plan says the approved authorization/referral on file does not match. Enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for destruction of malignant lesion (eg, laser surgery, 
electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia (17272) 
provided on May 9, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Med Mizer Active Care rotating pivot bed. 
 
You asked the Plan to pre-approve a pivot bed. You say that the pivot bed helps you up, helps you with daily 
activities and helps to sit up on your own. Your doctors also recommend this pivot bed for you. The Plan 
denied your request. The Plan says the requested pivot bed is not medically beneficial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a pivot bed. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation doesn't indicate that the requested bed will change your need to use a 
mechanical lift for transfers. There is no documentation that supports that you require this bed over a standard 
bed. The requested device has not been shown to be superior to other standard treatments for your medical 
condition. The brand name pivot bed is not medically necessary. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pivot bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Med Mizer Active Care rotating pivot bed.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 87801. We decided that the Plan does not have to pay for 87481, 
87640, 87653, and 87798.  
 
You asked the Plan to pay for procedure codes 87481, 87640, 87653, 87798, and 87801. The Plan says that the 
services are not payable. 
 
We decided that the Plan has to pay for code 87801 billed on March 24, 2021.  
 
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 87801 is Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. 
 
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 code 87801. Our reviewer says that the use of code 87801 is 
supported by the records provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87801 have been met. The records show that the testing in question was 
supported in the physician order. Therefore, we decided that the Plan has to pay for code 87801 billed on 
March 24, 2021.  
 
We also decided that the Plan does not have to pay for 87481, 87640, 87653, and 87798 billed on March 
24, 2021. 
 
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 codes 
87481, 87640, 87653, and 87798, are column II codes to column I code 87801. 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 87481, 87640, 87653, and 87798 
billed on March 24, 2021. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services provided to the enrollee on January 20, 
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 the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 
 CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 
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 in this case, there was not a nerve 
conduction study performed. The services reflected in this case relate to the performance of pedicle screw 
testing. This is considered to be part of the electromyography (EMG) services. Therefore, this service should 
not have been otherwise coded as a nerve conduction study. Therefore, CPT 95908 is not supported. 
Additionally, as there was not a nerve conduction study performed, the use of CPT 95885 would not have 
otherwise been considered to have been appropriate for the services provided. 
 
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 neurology services provided to the enrollee on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra battery pack for a portable oxygen concentrator 
(POC) (E1356). 
 
You asked the Plan to pre-approve an extra battery pack for a portable oxygen concentrator. You say that you 
need the additional POC battery because when you go to your appointments, the battery only lasts for 2 hours, 
and you are normally there longer. You also say you will be traveling to Tennessee and the airline has advised 
you need an additional battery pack. The Plan denied your request. The Plan says the item requested is not 
covered because it does not serve a diagnostic or therapeutic purpose and is not primarily medical in nature. 
 
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 extra battery pack for a portable oxygen concentrator 
(POC) (E1356).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge day management services (99239) provided on 
August 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
 
 We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge day management services were provided on the date of service in 
question. 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 discharge day management services 
(99239) provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) provided on February 23, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on February 23, 
2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on November 9, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that these items were medically necessary. 
The Plan denied your request. The Plan says this type of dressing is not covered. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on April 5, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee needs the hospital bed 
to help heal her bed sores and she cannot be put back into a bed that will cause her to get them again. The Plan 
denied your request. The Plan says the semi-electric bed is not reasonable or necessary. 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found according to Medicare 
a semi-electric hospital bed is medically necessary when a patients condition must require frequent changes in 
body position and/or there may be an immediate need for a change in body position and the patient can operate 
the controls and cause the adjustments. The documentation does not support that the enrollee has a condition 
that requires frequent positioning of the bed and mattress to alleviate pain, promote good body alignment, 
prevent contractures or avoid respiratory infections in a way that an ordinary bed is not able 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 a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (power scooter). 
 
You asked the Plan to pre-approve power scooter. You say that you are appealing this denial. The Plan denied 
your request. The Plan says a power scooter would not be helpful for you as the turning radius is too large for 
your home and you need more turning support than a scooter can give. 
 
The Plan follows Medicare rules. Medicare rules state that a power operated vehicle may be covered if certain 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve power scooter. Our reviewer says that 
you do not meet the Medicare criteria for the requested power scooter. Our physician reviewer found the 
documentation does not support that you will be able to use the requested power scooter to accomplish 
mobility-related self-care tasks in your 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 power scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (power scooter).