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

 
We decided that the Plan does not have to pay for the manual therapy (97140), therapeutic activities (97530), 
and the extra-spinal manipulative treatment (98943) provided from January 3, 2022, through June 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the manual therapy (97140), therapeutic activities (97530), and the extra-
spinal manipulative treatment (98943) provided from January 3, 2022, through June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unclassified drugs (J3490) provided on July 11, 2022. 
 
You asked the Plan to pay for the medication. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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 medication have not been met. The surgery procedure 
injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch (CPT code 64450) has a global 
surgery value of 000 on the Centers for Medicare & Medicaid Services (CMS) National Physician Fee 
Schedule (NPFS) Relative Value (RVU) file. This is an endoscopy or minor procedure that has a global surgery 
period for same day services as the surgery procedure. The denied service CPT code J3490 is included when 
billed within the global surgery period of the surgery procedure without an appropriate modifier. Therefore, we 
decided that the Plan does not have to pay for unclassified drugs (J3490) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cane, slide board, and a walker purchased between April 5, 
202, to May 22, 2022. 
 
You asked the Plan to pay for a cane, slide board, a walker and gel cushion. You say that you have the Wallet 
benefit that should cover the purchased items. The Plan denied your request. The Plan says items that are not 
listed under the Wallet Benefit cannot be reimbursed. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that Home Depot and Amazon are not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for a cane, slide board, and a 
walker purchased between April 5, 202, to May 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the combo power tilt and recline is 
needed to increase pressure distribution, manage spasticity, tone and pain. The requested accessories are 
needed for the enrollee's condition. The Plan denied your request. The Plan says although there are three 
requested power options, there is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollee has 3/5 strength and the enrollee's 
upper limb strength and function are adequate for the enrollee to be able to control the power options using 
their own switches which are included in the approved wheelchair. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hemoglobin testing (83036) provided on July 7, 2022. 
 
You asked the Plan to pay for hemoglobin testing. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this test was not medically 
necessary and was performed as a non-covered screening in this case. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The rules say that glycated hemoglobin and glycated 
protein testing is not medically necessary for the diagnosis of diabetes. 
 
The test at issue in this appeal, hemoglobin testing, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. The diagnosis code listed on this claim indicates that these lab 
services were provided for screening purposes as part of a wellness exam and there is no indication that the 
enrollee is diabetic. Therefore, we decided that the Plan does not have to pay for hemoglobin testing (83036) 
provided on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845) and addition to lower limb prosthesis, multiaxial ankle with swing phase active 
dorsiflexion feature (L5968). 
 
You asked the Plan to pay for the prosthetic accessories. You say that the attached documentation will show 
that the current prosthetic no longer meets the enrollee's needs and cannot be repaired. The Plan denied your 
request. The Plan says L5845 cannot be used for this device and is unbundled. Duplicate services cannot be 
covered. 
 
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 find that CPT code L5845 and L5968 are not supported in the medical record. Specifically, 
L5845 cannot be used for this device and is unbundled. The manufacturer does not recommend L5845 as 
bundled in this knee. L5986 does not represent a complete foot. It is part of a foot that must be paired with a 
complete foot based on the enrollee's functional classification. The request also includes two ankles. The 
request for the second ankle L5986, in addition to the approved ankle L5968 exceeds the enrollee's needs and 
cannot be covered. Based on this information, we decided that Medicare rules for coverage of the prosthetic 
accessories have not been met. Therefore, we decided that the Plan does not have to pay for an addition, 
endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and addition to lower limb 
prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI, spinal canal and contents, lumbar; without 
contrast material (code 72148) and an MRI, spinal canal and contents, cervical; without contrast material  
(code 72141). 
 
You asked the Plan to pre-approve the MRIs. You say that the requested MRIs are medically necessary. The 
Plan denied your request. The Plan says the requested MRIs are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI spinal canal and contents, 
lumbar; without contrast material (code 72148) and an MRI spinal canal and contents, cervical; without 
contrast material (code 72141). Our reviewer says that the requested MRIs are not medically necessary in this 
case.  Our physician reviewer found that the enrollee is a 71-year-old with non-specified abnormal gait and memory loss. The neurological exam is normal. There is no evidence of neck pain or radicular symptoms. An 
electromyography (EMG) is planned but not yet conducted. The medical necessity of the requested MRI of the 
cervical spine and lumbar spine has not been demonstrated in the records provided especially without the 
benefit of the planned EMG. 
 
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 MRI spinal canal and contents, lumbar; without contrast material 
(code 72148) and an MRI spinal canal and contents, cervical; without contrast material (code 72141) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an MRI spinal canal and contents, 
lumbar; without contrast material (code 72148) and an MRI spinal canal and contents, cervical; without 
contrast material (code 72141).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila (pegfilgrastim-jmdb) (CPT code Q5108). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the treatment you will be getting has a low risk of causing an infection, 
so it does not require the drug your doctor has requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found this regimen has less than 10 percent chance of causing febrile neutropenia; therefore, the medication 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Fulphila (pegfilgrastim-jmdb) (CPT code Q5108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 26, 2022, billed with 
codes 81455, 81301, and 81194. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
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 provided on 
July 26, 2022, billed with codes 81455, 81301, and 81194.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care associated with an elective lumbar 
laminectomy/laminotomy. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the elective procedure is medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that detailed documentation is evident regarding a significant past and/or current medical 
history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient 
stay. There is evidence of a planned major spine procedure (with potential for severe bleeding and severe pain 
issues) presented in an enrollee who is on long term anti-coagulants, along with hypertension and diabetes. 
This supports the medical necessity of this request. Therefore, the records show that at the time of inpatient 
admission the admitting physician would reasonably expect that the enrollees necessary hospital care will span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care associated with an elective lumbar laminectomy/laminotomy.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revenue codes 0250, 0258, 0272 and procedure codes C1713, 
62323, 99152, 99153, J0690, J2250, J3010 and Q9967 
 
You asked the Plan to pay for revenue codes 0250, 0258, 0272 and procedure codes C1713, 62323, 99152, 
99153, J0690, J2250, J3010 and Q9967. You say that you have provided medical records to support payment. 
The Plan denied your request. The Plan says there are several codes billed that are not separately payable.  In addition, the Plan says that for one of the codes billed (62323), the code is considered incidental to code 22514, 
and no modifier was billed along with this code to allow for payment. Because there were errors with the OPPS 
claim, the entire claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. In relation to codes 99152, 99153, C1713, J0690, J2250, J3010 and 
Q9967, Medicare rules say that codes with a status indicator of N are considered packaged services and no 
separate payment is made.  Codes 99152, 99153, C1713, J0690, J2250, J3010 and Q9967 all have a status 
indicator of N, so no separate payment can be made for these codes. 
 
In relation to code 62323, Medicare rules say that if a provider reports two codes of an edit pair, only the 
Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be paid 
regardless of whether a modifier is used. providers must report services correctly. In this case, we have 
confirmed that code 62323 is a column II code to column I code 22514 with a modifier indicator of 0. The 
column II code is therefore not payable.  Because there are non-payable codes and codes billed that have no 
separate payment allowed, the OPPS payment cannot be calculated (which is why the claim has denied). 
Therefore, we decided that the Plan does not have to pay for revenue codes 0250, 0258, 0272 and procedure 
codes C1713, 62323, 99152, 99153, J0690, J2250, J3010 and Q9967
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg replacement (L5850, L5920, L5925, 
L5930, L5950, L5984, L5999). 
 
You asked the Plan to pre-approve a prosthetic leg replacement. You say that you disagree with the denial. The 
Plan denied your request. The Plan says while notes from the prosthetist (vendor) state include L5920, the 
physician office visit notes do not corroborate the vendor's notes showing need to replace L5920. The use of 
additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4) as referenced in the 
LCD. Member already has an ankle approved: L5986. A second ankle (L5984) exceeds the member's needs 
and cannot be covered. Further, the requested foot is Fillauer Aeris Performance, which is properly coded 
L5981 + L5986 per manufacturer's website. L5884 is not part of this foot per manufacturer. Duplicate services 
are not covered by Medicare. 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 prosthetic leg replacement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical records do not provide specific information about the 
additional endoskeletal systems. The enrollee is a K3 ambulator. The medical record does not provide specific 
information why the enrollee requires the additional endoskeletal elements. The addition of the multiple 
endoskeletal elements does not have general literature support. Per Medicare A52496 the addition of these 
elements requires specific information not general statements about why the addition is necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a prosthetic leg replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a prosthetic leg replacement (L5850, L5920, L5925, L5930, L5950, L5984, 
L5999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately 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. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on July 06, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for office visits. 
 
You have been asked to pay a $30 copayment for office visit. This item/service falls within the office visits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. You 
have been asked to pay a $30 copayment for the office visit. The copayments for the imaging services have 
been dismissed. Therefore, we decided that the Plan does not have to waive the copayment for office visit 
provided on July 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 heavy duty power wheelchair, single power 
option, captains chair, patient weight capacity 301 to 450 pounds (K0859). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are appealing the denial because 
you really need the power wheelchair. The Plan denied your request. The Plan says the enrollee does not meet 
the medically necessary criteria for a power wheelchair. 
  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is able to walk 75 feet with a walker a powered wheelchair is not 
medically necessary per L33789. 
 
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 pre-approve the Group 3 heavy duty power wheelchair, single power option, captains chair, 
patient weight capacity 301 to 450 pounds (K0859).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extended respiratory panel provided on May 28, 2022. 
 
You asked the Plan to pay for the testing services. You say that the documentation supports the charges. The 
Plan denied your request. The Plan says a respiratory panel test is a single service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that the respiratory panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the extended respiratory panel provided on May 28, 2022.