Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2083 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code S2083. You say that the claim should be paid. 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 S2083 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2083 billed for date of service September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 22, 2022.

You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.

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 office visit have not been met. The documentation submitted does not support 99214 which was billed twice on July 22, 2022. The records submitted do not indicate that two separate services were performed/supported. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76770) provided on June 29, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the ultrasound. Our reviewer found review of the submitted 
records did not include a formal report of the retroperitoneal ultrasound of June 29, 2022. A few static images 
of the kidneys were included but in order to satisfy CMS requirements for reimbursement of retroperitoneal 
ultrasound, CPT 76770 a formal report describing the kidneys, aorta, vena cava needs to be documented and no 
record of such a report is in the submitted records. Absent such documentation the reimbursement for CPT 
76770 should be denied. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound (76770) provided on June 29, 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. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the services requested are not medically 
necessary. 
 
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 the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug will be administered by the 
physician, but not supplied by the physician. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the requested drug is not covered by Medicare 
Part B. The Plan says that they do not administer Part D benefits for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is needed to regain maximum function. The 
Plan denied your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code 77062. You say that the claim should be paid. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided May 20, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are 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 surgical services have not been met. Procedure code 15275 
denied as a low-cost skin substitute application procedure without any low-cost skin substitute product codes 
billed; therefore, the Medicare rule for payment of this claim has not been met. Therefore, we decided that the 
Plan does not have to pay for the surgical services provided May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested procedure is 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 a left heart catheterization. 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 no history of chest pain or dyspnea. Stress ECG test is of 
poor technical quality and no further stress imaging has been carried out. Documentation does not support the 
rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 
setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and 
necessary in this enrollee's 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 a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 
(93458).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 
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 hereditary cancer panel was billed with multiple codes, including code 81351. We find that the 
panel testing was not billed with a single code as required. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing services billed for date of service May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355-59 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 93355-59. You say that this is a separate billable code, hence the 
"59" modifier. The Plan denied your request. The Plan says payment for code 93355-59 is bundled into 
payment for code 00560. 
 
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 
93355-59 is a column II code to column I code 00560 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 93355-59 billed for date of service June 30, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve laparoscopy, surgical, repair of paraesophageal hernia, includes 
fundoplasty, when performed; with implantation of mesh (43282). 
 
You asked the Plan to pre-approve laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, 
when performed; with implantation of mesh (43282). You say that the requested laparoscopy, surgical, repair 
of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh (43282) is 
medically necessary. The Plan denied your request. The Plan says that the requested laparoscopy, surgical, 
repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh (43282) is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 laparoscopy, surgical, repair of 
paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh (43282). Our 
reviewer says that the requested laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, 
when performed; with implantation of mesh (43282) is medically necessary. Our physician reviewer found the 
record indicates that the enrollee has a recurrent hiatal hernia, gastroparesis and gastroesophageal reflux 
refractory to medical treatment. The record indicates that the enrollee has received cardiac clearance for 
surgery. The record provided establishes the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. The elements of the coverage criteria are satisfied. The requested service is 
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 laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, 
when performed; with implantation of mesh (43282) have been met. Therefore, we decided that the Plan has to 
pre-approve laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; 
with implantation of mesh (43282).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder laboratory testing (0012M) provided on July 
30, 2021. 
 
You asked the Plan to pay for the service. You say that the test can make a meaningful difference in the 
diagnosis and treatment of the enrollee. The Plan denied your request. The Plan says the service is not covered 
by Medicare or the Health Plan. 
 
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 service have not been met. The rules say non-coverage 
reaffirmed for CPT codes 0012M and 0013M for CXBLADDER. Therefore, this service is not covered. 
Therefore, we decided that the Plan does not have to pay for the CxBladder laboratory testing (0012M) 
provided on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the device is medically necessary. The Plan 
denied your request. The Plan says chronic bronchitis and chronic obstructive pulmonary disease (COPD) in 
the absence of a confirmed diagnosis of bronchiectasis do not meet criterion for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has COPD. There is no diagnosis 
of cystic fibrosis, bronchiectasis, or covered neuromuscular disease. There is insufficient evidence of safety and 
benefit in the treatment of COPD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart monitor device (transcatheter implantation of 
wireless pulmonary artery pressure sensor for longterm hemodynamic) (33289). 
 
You asked the Plan to pre-approve CardioMEMS procedure. You say that the requested procedure would help 
the enrollee treat his chronic systolic heart failure. The Plan denied your request. The Plan says there is not 
enough medical literature showing that this is safe and helpful, this cannot be approved per Medicare rules. 
 
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 CardioMEMS procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of patients with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, 
reflecting a patient population with preserved ejection fraction and was somewhat limited in scope (1). 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device (2). In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a heart monitor device (transcatheter implantation of wireless pulmonary 
artery pressure sensor for longterm hemodynamic) (33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted procedure, nervous system (64999) provided on 
June 21, 2022. 
 
You asked the Plan to pay for the service. 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 service have not been met. The billed procedure code 64999 is 
not included on Addendum AA --Final ASC Covered Surgical Procedures for Calendar Year 2022 and is not 
eligible for payment. Therefore, we find the Medicare rule for payment of code 64999 has not met. Therefore, 
we decided that the Plan does not have to pay for the unlisted procedure, nervous system (64999) provided on 
June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
The provider did not submit an order or information to verify the services were ordered from the treating 
physician. The rules say that the physician must clearly document, in the medical record, his or her intent that 
the test be performed. An order is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on February 28, 2022.