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

 
We decided that the Plan does not have to pay for the portable oxygen concentrator, rental (E1392) provided on 
July 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen equipment. You say that you are appealing to get some sort of 
reimbursement for the portable oxygen concentrator due to nobody having it available for rent or purchase in 
the system. 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 portable oxygen concentrator, rental (E1392) 
provided on July 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 22, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on July 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the member does not meet the Medicare criteria for 
LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
care. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service December 8, 
2021. 
 
You asked the Plan to pay for procedure code 88341. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services identified with codes 38220 and 0232T received 
on July 15, 2022. 
 
You asked the Plan to pay for the services identified with codes 38220 and 0232T. You say that you would like 
to be reimbursed for the services received. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
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 38220 and 0232T is diagnostic bone marrow; 
aspiration(s). 
 
We find that CPT code 38220 is not supported in the medical record. Specifically, this code requires an 
anatomical modifier. This modifier was not billed on the claim. In this case, we have confirmed that code 
0232T is a column II code to column I code 38220. 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. 
 
Based on this information, we decided that Medicare rules for coverage of the services identified with codes 
38220 and 0232T have not been met. Therefore, we decided that the Plan does not have to pay for the services 
identified with codes 38220 and 0232T received on July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and appliance 
(E0673) provided on January 12, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) and appliance (E0673) provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal photopheresis (36522) provided August 8, 
2022. 
 
You asked the Plan to pay for the outpatient procedure. You say that Please review and reconsider for payment 
due to medical necessity. Attached are records for your review. The Plan denied your request. The Plan says 
this service is not covered per the Medicare NCD. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the outpatient procedure. 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 chronic bronchitis. Extracorporeal Photopheresis (36522) was 
requested. However, the enrollee does not have a covered indication for this procedure. There is no evidence of 
bronchiolitis obliterans syndrome following lung transplantation. Therefore, the medical records provided do 
not meet the requirements listed in the NCD for Medicare coverage. 
 
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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for extracorporeal photopheresis (36522) provided August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code U0004 billed for date of service August 14, 
2021. 
 
You asked the Plan to pay for procedure code U0004. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code U0004 is bundled into payment for code U0003. 
 
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 U0004 
is a column II code to column I code U0003 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 U0004 billed for date of service August 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inversion table (E1399). 
 
You asked the Plan to pre-approve an inversion table. You say that you disagree with the denial. The Plan 
denied your request. The Plan says an inversion table is non-covered because they are 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 inversion table (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
pneumatic appliance, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the requested 
services are needed for the enrollee's leg swelling. The Plan denied your request. The Plan says medical records 
do not indicate that the enrollee has truncal or abdominal lymphedema. Notes describe a large pannus, for 
which an advanced PCD is not indicated. Lymphedema of the trunk or abdomen is not described. The enrollee 
does not meet criteria for approval. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a pneumatic appliance, full leg (E0667).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services identified with codes 83789 and G0481 provided
on July 7, 2022.

You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan
denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory
directly. Medicare rules also say that providers must report services correctly. Providers must report services
with the appropriate CPT code. The rules also state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.

In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified,
qualitative or quantitative, each specimen.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the lab services have not been met. We find that CPT code 83789 is not supported in the medical
record. Specifically, this code is not separately reimbursed when billed for specimen validity testing on
specimens used for drug testing. Mass spectrometry and tandem mass spectrometry is considered inappropriate
to bill in addition to drug testing as it is inclusive to the service. This means that code 83789, billed with the -
59 modifier is not a distinct procedural service. In addition, this claim was billed with the laboratory POS code.
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the
Plan does not have to pay for lab services identified with codes 83789 and G0481 provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet injection, lumbar/sacral. 
 
You asked the Plan to pre-approve a facet injection, lumbar/sacral. You say that a facet injection, lumbar/sacral 
is medically necessary. The Plan denied your request. The Plan says the requested facet injection, lumbar/sacral 
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 a facet injection, lumbar/sacral. Our reviewer says that a facet injection, lumbar/sacral is not medically necessary in this case. Our physician 
reviewer found that in this case there, there is documentation of lumbar radiculopathy. The review has 
determined that the requested facet joint injection does 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 a facet injection, lumbar/sacral have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a facet injection, lumbar/sacral.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 13, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81328, 81355, and 81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 13, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81328, 
81355, and 81407.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve ablation/destruction (64640). 
 
You asked the Plan to pre-approve a peripheral nerve ablation/destruction. You say that you have been having 
knee pain for over a year. You also say that you are not a good candidate for knee replacement, have tried other 
remedies, and a neuroablation has been recommended. The Plan denied your request. The Plan says peripheral 
nerve ablation outside of the spine is 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.  
 
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 peripheral nerve ablation/destruction. 
Our reviewer says that a peripheral nerve ablation/destruction is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that you have knee pain. There is 
insufficient literature to support the medical necessity of the requested service for the enrollee's specific clinical 
condition. Our reviewer found that the record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. Our physician reviewer also found that the requested service is not recommended. 
 
 
 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 peripheral nerve ablation/destruction have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a peripheral nerve ablation/destruction (64640).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 77078 and 99215 for services provided on June 28, 
2022. 
 
You asked the Plan to pay for codes 77078 and 99215. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes 77078 and 99215 are not supported in the medical record. Specifically, code 77078 
was billed with diagnosis codes M859, Z08 and Z8546. The diagnosis relationship has not been met per coding 
guidelines. Code 99215 was billed without a modifier to indicate that this service was separately identifiable.  
Based on this information, we decided that Medicare rules for coverage of codes 77078 and 99215 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 77078 and 99215 for services 
provided on June 28, 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. The Plan denied your request. The Plan says the records do not 
show that you are able to take part in 3 hours of therapy a day at least 5 days a week or 15 hours per week. 
Services needed may be provided safely in other settings, a skilled nursing facility, 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 that your medical records support 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted medical records do not 
document any spinal instability, fracture, or lesion. The records do not support that the requested spinal fusion 
is reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar spinal fusion.  
 Local Coverage Determination (LCD) L33382 referenced by the Plan is not valid for the state of Colorado and 
was not used in the MAXIMUS determination.