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

 
We decided that the Plan does not have to reimburse you for the portable oxygen equipment (E1392), batteries 
(E1999), and shipping cost (A9901) provided on May 10, 2022. 
 
You asked the Plan to reimburse you for the shipping cost. You say that you rented a portable oxygen 
concentrator to fly. You also say that you returned it once you reached your destination. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the shipping cost have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the portable oxygen equipment (E1392), batteries (E1999), and shipping cost (A9901) 
provided on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services identified with codes 80053 and 85025 
provided on November 15, 2022. 
 
You asked the Plan to pay for odes 80053 and 85025. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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, odes 80053 and 85025, 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 laboratory services identified with codes 80053 and 85025 provided on November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee is non-weight bearing 
and requires some assistance for mobility-related tasks. The Plan has approved a wheelchair for five months. 
The use of the wheelchair beyond the approved five months is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of skin electrodes and measurement of 
stimulated sites in trunk or head (95927) and a measurement of the brain wave activity (EEG), in coma or 
asleep (95822), provided on March 15, 2022. 
 
You asked the Plan to pay for the somatosensory testing and EEG. You say that the claim should be paid as 
billed. The plan denied your request. The Plan says current procedural terminology (CPT) codes 95927 and 
95822 remains 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 95927 and 95822 is short-latency somatosensory evoked 
potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous 
system; in the trunk or head and an electroencephalogram (EEG); recording in coma or sleep only. 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 somatosensory testing and EEG. Our reviewer says that 
the documentation does not support procedure code(s) 95927 and 95822. Our reviewer found that the 
procedure report does not provide clear documentation to support the placement of skin electrodes and 
measurement of stimulated sites in trunk or head (95927) and a measurement of the brain wave activity (EEG), 
in coma or asleep (95822) billed was provided. 
 
Key elements of the CPT code descriptions are not present in the record. There are more fitting codes for the 
procedures performed, therefore the denial is upheld. 
 
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 somatosensory testing and EEG have not been met. Therefore, we decided 
that the Plan does not have to pay for the placement of skin electrodes and measurement of stimulated sites in 
trunk or head (95927) and a measurement of the brain wave activity (EEG), in coma or asleep (95822), 
provided on March 15, 2022.
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 
14, 2022. 
 
You asked the Plan to pay for procedure code 77062. You say that the services were medically necessary. 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 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care beyond April 1, 2023. 
 
You asked the Plan to pre-approve continued SNF care beyond April 1, 2023. You say that you are worried 
about your health and needs to have the ability to care for yourself before you go home. The Plan denied your 
request. The Plan says continued skilled nursing facility (SNF) coverage beyond April 1, 2023, is not medically 
indicated. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care beyond April 1, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the SNF is medically necessary. The Plan denied 
your request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as home health or outpatient services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when there is a 
need to separate a differential diagnosis of frontotemporal dementia and Alzheimers disease. 
 
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 of the brain. Our reviewer 
says that the requested service is not medically necessary. Our physician reviewer found the records provided 
for review only indicated that the enrollee was suspected of having Alzheimer's Dementia. The enrollee was 
not suspected of having FTD as well. Therefore, there would not be an indication to perform a PET scan of the 
brain to differentiate between the two conditions.  
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 of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 office visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve 6 office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
6 office visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs Micrographic Surgery (MMS). 
 
You asked the Plan to pre-approve MMS. 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 MMS is covered when specific criteria are met. 
 
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 MMS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Mohs procedure is not required for 
tumor excision in that skin region. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Mohs Micrographic Surgery (MMS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266) Tooth #7 and 10. 
 
You asked the Plan to pre-approve dental services. You say that the services are needed for the enrollee to 
complete the treatment plan. The Plan denied your request. The Plan says this service is not covered under your 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Guided tissue regeneration - 
resorbable barrier, per site (D4266) is not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4266 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve guided 
tissue regeneration - resorbable barrier, per site (D4266) Tooth #7 and 10.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36415 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 36415. You say that you disagree with the denial. 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 36415 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code 36415 is statutorily excluded from Medicare purposes. Based on this information, we decided 
that Medicare rules for coverage of procedure code 36415 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 36415 billed for date of service July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 84480. You say that this service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 84480 is bundled into payment for code 
84481. 
 
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 84480 
is a column II code to column I code 84481 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 84480 billed for date of service February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), harness for upgrade to expandable controller (E2313), 
and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. 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 power wheelchair accessories are covered when 
specific criteria are met. 
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the enrollee has adequate strength in her upper extremity to manage multiple standard power switches. 
The requested accessories are not necessary to meet enrollee's needs. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair 
controller and two or more power seating system motors (E2311), harness for upgrade to expandable controller 
(E2313), and expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 
14, 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 December 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic radiologic exams coded as 74230, 72040, 
70100, 70310, and 74240 provided October 11, 2022. 
 
You asked the Plan to pay for the diagnostic services. You say that this service was of medical necessity. These 
services were performed at the request of the primary care physician at the facility. You are contracted with this 
facility. Therefore, these services should be paid. The Plan denied your request. The Plan says the records show 
that CPT codes 74240 and 74230 were performed in an excluded place of service (POS) 11 and is not covered. 
The records did not support that CPT codes 70100, 70310 and 72040 were 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 pay for the diagnostic services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the review indicates that the enrollee has Barrett's 
esophagus and was evaluated for dysphagia. The denials for CPT 74240 and 74230 have been upheld. Per the 
enrollees policy/coverage, the services are not a covered benefit as it is listed under the Limitations and 
Exclusions section for the code billed. This service is not a covered benefit under the enrollees Plan and is not 
eligible for reimbursement per the Medicare Benefit Policy Manual; Chapter 15 80.4.4 - Exclusions from 
Coverage as Portable X-Ray Services. The review has determined that the procedure codes 70100, 70310 and 
72040 at issue in this case were not medically reasonable and necessary for coverage. The medical records 
provided did not support that procedure codes 74240 and 74230 met the requirements for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan 
does not have to pay for the diagnostic radiologic exams coded as 74230, 72040, 70100, 70310, and 74240 
provided October 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment 
of the enrollee's health problem 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the bone marrow aspirate is experiential when used as bone graft material in spinal surgery. 

More research is needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (20939).