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

 
We decided that the Plan does not have to pay for procedure code 99152 provided on September 20, 2022. 
 
You asked the Plan to pay for procedure code 99152. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported 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. 
 
In this case, the CPT Code Manual definition of code 99152 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; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99152 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99152 provided on 
September 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
10, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. 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 for the HCPCS/CPT code will be denied. 
 
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 line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 November 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim was denied as a duplicate in error. 
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 for the HCPCS/CPT code will be denied. 
 
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 line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 November 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic gastric restrictive procedure. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that bariatric surgery is covered for the indications 
established in the applicable LCD. 
 
We looked at the file and Medicare rules. In this case, the records do not show that your BMI is greater than 35. 
Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a laparoscopic gastric restrictive procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on October 
17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebral augmentation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you 
have severe spinal stenosis/canal compromise at the level of the compression fracture. 
 
The Plan follows Medicare rules. Medicare rules say that vertebral augmentation is only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the imaging studies show spine vertebral body bone retropulsion which is a 
contraindication. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vertebral augmentation services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body (78816).

You asked the Plan to pre-approve a PET scan. You say that you disagree with the denial. The Plan denied your request. The Plan says the medical records do not show that the enrollee has active malignancy or is currently receiving treatment for malignancy. Based on the additional information available, the request does not meet the Medicare or health plan coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found the review indicates that the enrollee has a remote history of cutaneous T-cell lymphoma in the 1960s and faint IgM kappa monoclonal restriction with a stable monoclonal gammopathy. The enrollee has declined a bone marrow biopsy and does not have established multiple myeloma, per the medical records received. A prior PET/CT in 2021 showed no evidence of active lymphoma or other suspicious findings. A surveillance PET/CT was ordered. Per the PET/CT NCD, an FDG PET/CT is covered for lymphoma or multiple myeloma while receiving treatment to assess antitumor treatment strategy. The medical records do not show that the enrollee has active malignancy or is currently receiving treatment for malignancy. The enrollee does not have an indication for which a PET Scan can be covered at this time.

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body (78816).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat function program (K0108). 
 
You asked the Plan to pre-approve a seat function program. You say that this is a switch that is required to 
operate the power tilt function and power foot platform. Without the switch this motorized wheelchair power 
seating functions cannot be operated. The enrollee requires the requested switch to be operate the motorized 
wheelchair. The Plan denied your request. The Plan says the seat function through the switch is already 
included with the requested expandable controller. This item should not be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollee was approved for a power 
wheelchair and requested accessories including an expandable controller. The records also show that the 
requested seat function program is included with the approved expandable controller. Based on this 
information, we decided that Medicare rules for coverage of a seat function program have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a seat function program (K0108).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport  provided on September 20, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport. You say that this 
was an emergency because you were bed bound and could not get out of bed. The Plan denied your request. 
The Plan says the ambulance transport was not medically necessary 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance service, basic life support, 
emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our 
physician reviewer found you did not require the expertise of trained personnel or the equipment available only 
on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other 
means (stretcher van, wheelchair van, private car, taxi) without endangering your condition. 
 
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 ambulance service, basic life support, emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, 
emergency transport  provided on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D; 25 hydroxy (82306), Cyanocobalamin 
(Vitamin B-12) (82607), folic acid; serum (82746), and magnesium (83735) testing provided on June 5, 2022.  
You asked the Plan to pay for the Vitamin D, Vitamin B-12, folic acid and magnesium testing. You say that 
this testing was medically necessary. The Plan denied your request. The Plan says these tests are not a 
Medicare benefit for the diagnosis listed on the claim and are done for screening purposes. 
 
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, the Vitamin D, Vitamin B-12, folic acid and magnesium testing, 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 Vitamin D; 25 hydroxy (82306), Cyanocobalamin (Vitamin 
B-12) (82607), folic acid; serum (82746), and magnesium (83735) testing provided on June 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87801, 87150) provided on April 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services 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 (87801, 87150) provided on April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
August 24, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the skin protection and positioning wheelchair seat cushion, 
adjustable, width less than 22 inches, any depth (E2624). 
 
You asked the Plan to pre-approve the wheelchair seat cushion. You say that a new Roho cushion for the power 
wheelchair is medically necessary. The Plan denied your request. The Plan says that the records do not support 
that the enrollee meets the criteria. 
 
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 the wheelchair seat cushion. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has impaired strength with a glycogen storage disease impacting 
muscle function. The record indicates the enrollee is able to stand and take a few steps. Per note from 
physician, with an addendum written 5 months after record not showing skin breakdown and added in response 
to denial stating the enrollee has skin breakdown. The physician has asserted the enrollee does indeed have 
significant pressure ulcers. 
 
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 wheelchair seat cushion have been met. Therefore, we decided that the Plan 
has to pre-approve the skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 
inches, any depth (E2624).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99497 billed for dates of service 
from March 14, 2022, to March 15, 2022. 
 
You asked the Plan to pay for procedure codes 99233 and 99497. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says payment for codes 99233 and 99497 is bundled 
into payment for code 99223. 
 
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 99233 
and 99497 are column II codes to column I code 99223. This claim has not been billed with appropriate 
modifiers to bypass the edit. 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 codes 99233 and 99497 billed for dates 
of service from March 14, 2022, to March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with codes 28715 and 27685 for 
September 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 procedure codes 28715 and 27685 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 28715 is arthrodesis; triple. The definition of code 27685 
is lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure). 
 
We find that CPT codes 28715 and 27685 are not supported in the medical record. Specifically, there is no 
documentation of a triple arthrodesis to support code 28715. There is no documentation of additional work to support the billing of the -22 modifier for code 27685. 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 
pay for the surgical services billed with codes 28715 and 27685 for September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care billed with code 99222 for April 12, 
2022, to April 13, 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 procedure code 99222 is 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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, there is no documentation of 
a comprehensive history and comprehensive examination. 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 
pay for the initial hospital care billed with code 99222 for April 12, 2022, to April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omni display cable (K0108). 
 
You asked the Plan to pre-approve an Omni display cable. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested item is not covered under Medicare. The cable is included in 
the allowance for the Omni control module. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the requested display cable is included in the 
allowance for the Omni control module and is not available for separate payment. Based on this information, 
we decided that Medicare rules for coverage of an Omni display cable have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Omni display cable (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex lumbar interspinous decompression device 
coded as 22867 and 22868. 
 
You asked the Plan to pre-approve the Coflex device. You say that you are appealing the denial as the enrollee 
is getting worse clinically. The Plan denied your request. The Plan says the Coflex lumbar interspinous 
decompression device is unproven and not medically necessary due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There are not enough studies on Coflex to show it is safe and 
effective. Based on this information, we decided that Medicare rules for coverage of the Coflex device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex lumbar interspinous 
decompression device coded as 22867 and 22868.