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

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization 
(37220, 37221, 37224, 37225, 37226, 37227). 
 
You asked the Plan to pre-approve lower extremity angiography and revascularization. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 lower extremity angiography and 
revascularization. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the enrollee has evidence of lower extremity arterial disease, but the evidence does not confirm the 
presence of severe arterial stenosis, nor evidence that the claudication symptoms are of sufficient severity that 
they interfere with activities of daily living. Moreover, the records do not show that guideline-directed medical 
therapy, such as a program of structured exercise, has been carried out. As such, guidelines for peripheral 
revascularization are not met. In summary, there is insufficient documentation to support the medical necessity 
for peripheral revascularization in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lower extremity angiography and revascularization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lower extremity angiography and 
revascularization (37220, 37221, 37224, 37225, 37226, 37227).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 11, 2022, to 
September 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 11, 2022, to 
September 9, 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. The Plan denied your request. The Plan says the 
enrollee is receiving the care needed in the current hospital and there is no need to transfer to the LTACH at 
this time. 
 
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 enrollee appears to be currently unstable for transfer and requires short-term 
additional acute care services that can safely be provided at the current facility until more stable for transfer. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the medical records support multiple 
procedures on this date. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one unit with the LT modifier and one with the RT modifier 
instead of billing a single line item with the bilateral modifier. Based on this information, we decided that 
Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76641 billed for date of service October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis and addition to lower extremity provided on 
September 2, 2022. 
 
You asked the Plan to pay for the hip orthosis and addition to lower extremity. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the documentation submitted did not sufficiently 
support the billed supply codes 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the medical records provided to not include reasoning as why the 
billed items were necessary. The documentation submitted did not sufficiently support the billed supply codes. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the hip orthosis and addition to lower extremity 
provided on September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses, the transitions, the Hi-index lenses, 
the anti-reflective coating, and the lens wipes provided on May 24, 2022. 
 
You asked the Plan to pay for the progressive lenses, the transitions, the Hi-index lenses, the anti-reflective 
coating, and the lens wipes. You say that you are appealing the billed amount. The Plan denied your request. 
The Plan says the claim processed correctly. 
 
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 does not cover these services. 
 
We looked at the file and the Plan's rules. Specifically, the services are not covered benefits. Please note, 
although progressive lenses are not covered under the EOC, the Plan has chosen to partially cover this item 
with a $150 copayment. Based on this information, we decided that the Plan's rules for coverage of the 
progressive lenses, the transitions, the Hi-index lenses, the anti-reflective coating, and the lens wipes have not 
been met. Therefore, we decided that the Plan does not have to pay for the progressive lenses, the transitions, 
the Hi-index lenses, the anti-reflective coating, and the lens wipes provided on May 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9366 billed for date of service September 
16, 2022, to September 22, 2022. 
 
You asked the Plan to pay for procedure code S9366. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 S9366 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9366 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9366 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9366 billed for date of service September 16, 2022, to September 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 44620 for August 9, 
2022. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules state that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery are included in the global surgical package. 
 
We looked at the file and Medicare rules. Procedure code 44620 was related to and billed within 90 days of 
major surgical procedure billed with code 44310 for June 10, 2022. Payment for code 44620 is included in the 
global surgical package. Therefore, we decided that the Plan does not have to pay for the surgical services 
billed with code 44620 for August 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that multiple procedures were performed on this 
date. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (93970) provided on July 25, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 code 93970 is not supported in the medical record. Specifically, a bilateral procedure was 
performed. A left and right diagnosis code was billed when there was a more appropriate (bilateral) code. 
Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. 
Therefore, we decided that the Plan does not have to pay for a duplex scan (93970) provided on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87591, 87661, 87651, 87563, 
87640, 87653, 87641, 87500, 87798) provided on March 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (87481, 87491, 87591, 87661, 87651, 87563, 87640, 87653, 
87641, 87500, 87798) provided on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extra-spinal chiropractic manipulative treatment (98943) 
and the therapeutic exercises (97110) provided on September 20, 2022. Additionally, the Plan does not have to 
waive the copayment for the chiropractic manipulative treatment (98941) provided on September 20, 2022.  
 
You asked the Plan to pay for the extra-spinal chiropractic manipulative treatment and the therapeutic 
exercises. You also asked the Plan to waive the copayment for the chiropractic manipulative treatment 
provided. 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. Additionally, the Plan says the cost sharing 
was applied correctly to the chiropractic manipulative treatment provided.  
 
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 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 $20 copayment per visit for Medicare-covered 
chiropractor services. 
 
The records show that the services at issue (98943 and 97110) are not manual manipulation of the spine. The 
Plan is not holding you liable for procedure codes 98943 and 97110. The record indicates that you are being 
balance billed by the provider. The balance bill is not your responsibility or the responsibility of the Plan. 
Please contact your Medicare Regional Office with any questions or concerns about this bill. Furthermore, 
review of the file shows that you received chiropractic manipulative treatment (CMT); spinal, 3-4 regions 
(98941) provided on September 20, 2022. You have been asked to pay a $20 copayment for the chiropractor 
services. The 2022 Evidence of Coverage booklet states that enrollees must pay a $20 copayment per visit for 
Medicare-covered chiropractic services. Covered services include: Only manual manipulation of the spine to 
correct a subluxation. This service falls within the Chiropractic services 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. Therefore, the Plan does not have to 
pay for the extra-spinal chiropractic manipulative treatment (98943) and the therapeutic exercises (97110) 
provided on September 20, 2022. Additionally, the Plan does not have to waive the copayment for the 
chiropractic manipulative treatment (98941) provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 wheelchair and power options (K0862, 
E2363, E1007, E2311, E2605, K0040, E0955, E1028, E0953, E2377, E2313, E1020). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says the 
enrollee does not have a qualifying diagnosis causing mobility limitation for which a group 3 power wheelchair 
is medically needed. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
morbid obesity. He is non ambulatory but independent in ADLs. The enrollee is not at high risk for skin 
breakdown, does not have spasticity or use intermittent catheterization. He does not require power, recline, and 
tilt. He has adequate strength to manage any standard switches on his power wheelchair. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 wheelchair and power options (K0862, E2363, E1007, 
E2311, E2605, K0040, E0955, E1028, E0953, E2377, E2313, E1020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that the enrollee will benefit from a motor scooter as he 
is still having pain in the amputated leg. This leaves him unable to use a walker or cane. He cannot stand for 
long periods of time. A motor scooter will also benefit the enrollee and his caretaker as it will help him move 
more on his own. The enrollee does have function of his hands and will be able to maneuver the scooter. The 
Plan denied your request. The Plan says the requested scooter does not meet the requirements for approval. For 
a scooter, the enrollee must be able to maintain upright posture while seated and safely use a scooter. The 
records do not show inability to use a manual wheelchair or documentation of a home evaluation or enough 
room in the enrollee's home for use of the requested device. 
 
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 a scooter. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation indicates the enrollee has 
a mobility limitation, but it is not clear that this limitation significantly impairs his ability to participate in one 
or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, 
and bathing in customary locations in the home. The documentation does not support that the enrollee's 
mobility limitation cannot be sufficiently resolved using an appropriately fitted walker or manual wheelchair or 
that the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for use of 
the manual wheelchair that is requested. The documentation does not support that the use of the scooter will 
significantly improve the enrollee's ability to participate in MRADLs and he will use it on a regular basis in the 
home. There are no detailed objective exam findings of strength, endurance, range of motion, or coordination, 
presence of pain, or deformity of the bilateral upper and lower extremities. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and including 300 
pounds (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided September 1, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the prescribing physician recommends an 
extended lifetime use of equipment as the enrollee is diagnosed with chronic pain and compromised mobility 
without the option for surgical correction. The Plan denied your request. The Plan says there is evidence of 
misrepresentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the submitted packaging slip and proof of deliver 
belong to date of service August 4, 2022. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided September 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for muscle transfer services identified with code 23397 provided 
on August 1, 2022. 
 
You asked the Plan to pay for muscle transfer services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 23397 is muscle transfer, any type, shoulder or upper 
arm; multiple. 
 
 
 We find that CPT code 23397 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a muscle transfer; therefore, this code cannot be verified. Based on this information, 
we decided that Medicare rules for coverage of muscle transfer services have not been met. Therefore, we 
decided that the Plan does not have to pay for muscle transfer services identified with code 23397 provided on 
August 1, 2022.