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

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
(0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart Implantable Pulse Generator. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
medical necessity rules for coverage of the requested services have not been met. 
 
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 an Optimizer Smart Implantable Pulse 
Generator. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that cardiac contractility modulation remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit. 
 
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 Optimizer Smart Implantable Pulse Generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
(0408T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
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 test at issue in this appeal, a cardiac risk assessment panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and multiple power 
options/accessories for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not 
document that the enrollee uses intermittent urinary bladder catheterization, has increased muscle tone or 
spasticity or has severe lower extremity edema to meet criteria for the power recline or elevating leg rests. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 power wheelchair and multiple power options/accessories for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on November 
17, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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. 
 
The file shows that CPT code 70450 was billed on the same date of service as code 70496. We find that CPT 
code 70450 may be eligible for payment when billed with this code pair. The claim information does not show 
that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided 
that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does 
not have to pay for the computed tomography (CT) scan provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on December 3, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that you were not aware this service would not be 
covered, and you were not expecting this additional cost. The Plan denied your request. The Plan says this 
service is not covered by Medicare, and because it was performed as part of a medical (Medicare-covered) eye 
exam, it is also not covered by the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions only when they are provided as part of a routine (non-medical) eye 
exam. 
 
We looked at the file and the Plan's rules. The eye refraction in this case was provided as part of a medical eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on 
December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), scaling and root planing for 1 to 3 
teeth per quadrant (D4342), scaling and root planing for 4 or more teeth per quadrant (D4341 x 3), and 
extractions (D7140 x 4) provided from August 18, 2021, to November 10, 2021 by the opt out provider. 
 
You asked the Plan to pay for the dental services. You say that an exception should be made for the services in 
this case. You also say that you were not aware that the enrollee was being harmed as a result of your decision 
to be an opt out provider. The Plan denied your request. The Plan says payment cannot be made to a provider 
that has opted out of Medicare. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the oral exam (D0120), scaling and root planing for 1 to 3 teeth per 
quadrant (D4342), scaling and root planing for 4 or more teeth per quadrant (D4341 x 3), and extractions 
(D7140 x 4) provided from August 18, 2021, to November 10, 2021 by the opt out provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
14, 2021. 
 
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 these services are related to the treatment of ESRD. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 
laboratory services provided to the enrollee on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen handling services rendered on November 22, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99000 (handling and/or conveyance of 
specimen for transfer from the office to a laboratory) has a status indicator of B and no separate Medicare 
payment. Therefore, we decided that the Plan does not have to pay for the specimen handling services rendered 
on November 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Patisiran. 
 
You asked the Plan to pre-approve Patisiran. You say that you are overdue for treatment. The Plan denied your 
request. The Plan says the denial of authorization for this drug is correct, because this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Patisiran. Our reviewer says that you do 
not meet the Medicare criteria for the requested use of Patisiran. Our physician reviewer found Patisiran is 
Food & Drug Administration (FDA) approved for your condition. However, the requested use is not indicated 
or supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved 
medical journal. Accompanying use of Patisiran and Vyndamax is not supported as safe and effective and 
otherwise reasonable and necessary for you. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Patisiran have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Patisiran.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the introduction of needle or intracatheter (36000) provided 
on July 6, 2021. 
 
You asked the Plan to pay for the introduction of needle or intracatheter (36000). You say that the patient went 
into the emergency room and was seen by the physician for a medically necessary procedure. You say that the 
claim should be reprocessed to pay this procedure. The Plan denied your request. The Plan says bundled 
services are not eligible for separate payment. 
 
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 36000 is introduction of needle or intracatheter, vein. 
 
  We find that CPT code 36000 is not supported in the medical record. Specifically, CPT code 36000 has a status 
indicator of B. This means that CPT code 36000 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the introduction of needle or intracatheter 
(36000) have not been met. Therefore, we decided that the Plan does not have to pay for the introduction of 
needle or intracatheter (36000) provided on July 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on August 4, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you did not request for the ambulance to be 
called. You say that you were not treated by the ambulance company. You say that you did sign off stating you 
did not want to go to the hospital. You also say that you should not have to pay for this service. The Plan 
denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 4, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemorrhoidectomy (46260) provided on December 3, 
2021. 
 
You asked the Plan to pay for the hemorrhoidectomy (46260). You say that the surgical assistant was chosen 
by the surgeon and provided the services in the best interest of the patient. You say that all services were 
medically necessary, and you are requesting review for payment in full. The Plan denied your request. The Plan 
says an assistant at surgery may not be paid for this procedure. 
 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 46260. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
hemorrhoidectomy (46260) have not been met. Therefore, we decided that the Plan does not have to pay for the 
hemorrhoidectomy (46260) provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 22, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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. In this case, this claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on September 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 
19, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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. 
 
The file shows that CPT code 70450 was billed along with CPT code 70496. We find that CPT code 70450 
may be eligible for payment when billed with this code pair. The claim information does not show the code at 
issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare 
rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay 
for the computed tomography (CT) scan provided on December 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist x-ray rendered on January 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 73100 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 73100 (wrist x-ray, 2 views) and 73110 (wrist x-ray, 
minimum of 3 views). Code 73100 is a column II code with a modifier indicator of 1 when billed with column 
I code 73110. Code 73100 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the wrist x-ray rendered on January 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
December 21, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that procedure 99153 is no 
longer included in the primary procedure and was necessary to treat the patient. You say code 99153 supported 
in the attached documentation and should be processed for payment. The Plan denied your request. The Plan 
says CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient 
department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum pump addition to a lower limb prosthesis 
(L5781). 
 
You asked the Plan to pre-approve a vacuum pump addition to a lower limb prosthesis. You say that the 
requested item is a medical necessity for you. The Plan denied your request. The Plan says medical necessity 
rules for the requested item have not been met. 
 
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 addition to a lower 
limb prosthesis. Our reviewer says that the requested item is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the requested item exceeds your medical needs and is not proven to 
be superior to the approved standard socket. 
 
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 addition to a lower limb prosthesis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a vacuum pump addition to a lower limb 
prosthesis (L5781).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment (E1390 and A9270) purchased on 
November 23, 2021. 
 
You asked the Plan to pay for the oxygen equipment. You say that you would like reconsideration because you 
were told this would be covered as long as you had a prescription. The Plan denied your request. The Plan says 
oxygen-related equipment rental is 36 months before ownership transfers to you. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Specifically, the documentation submitted indicates that 
you purchased the oxygen equipment. Per Medicare and the Plan, oxygen-related equipment must be rented for a 36 month period before ownership transfers to you. Therefore, we decided that the Plan does not have to pay 
for the oxygen equipment (E1390 and A9270) purchased on November 23, 2021.