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

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
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 12013 is "Simple repair of superficial wounds of face, 
ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation describes a 
simple repair to a right anterior shin laceration. In this case, CPT 12013 includes simple repair of face, ears, 
eyelids, nose, lips and/or mucous membranes. Therefore, this procedure cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on May 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your 
request. The Plan says the services are not urgent, emergent, or approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on 
July 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 14, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no documented result of a prior prostate biopsy. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found screening services without a valid medical diagnosis related to the health of the patient are not a benefit. 
This testing can be considered with previous negative prostate biopsy who are being considered for repeat 
biopsy is promising with evidence of some clinical utility to reduce unnecessary repeat prostate biopsies. There was no documented result of prior prostate biopsy. There was no documented significant interval increase in 
prostate-specific antigen (PSA) level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
October 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no additional documentation supporting an additional study which was billed and 
remains denied. 
 
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 the denied codes is: 
 
CPT 77063: 
 
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) 
 
CPT 77067: 
 
Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) 
when performed 
 
We find that CPT code 77063 and 77067 is not supported in the medical record. Specifically, there is no 
evidence that these services were done more than once in this case. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional imaging services provided to the enrollee on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on November 19, 
2021 and billed under code 81479 for BluePrint testing. 
 
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says the Blueprint testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules specifically state this testing is excluded from coverage.  
Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on 
November 19, 2021 and billed under code 81479 for BluePrint testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopy services provided to the enrollee on March 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service should not be unbundled. 
 
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 76000 
is a column II code to column I code 33208. This claim has not been billed with an appropriate modifier 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 fluoroscopy services provided to the enrollee on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. 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 the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the Life2000 System is not 
medically necessary. This system is intended to provide positive pressure oxygen via nasal cannula during 
activity. It is not a true ventilator because it is not capable of providing full ventilatory support. There is 
inadequate evidence from clinical trials that it is effective in the treatment of chronic obstructive pulmonary 
disease (COPD). The enrollee does have COPD, but an arterial blood gas analysis (ABG) shows no significant 
carbon dioxide (CO2) retention. Therefore, the enrollee does not meet criteria for ventilatory support during 
sleep. Medicare does not cover a home ventilator when used as bilevel positive airway pressure (bipap). 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek smartview strips. 
 
You asked the Plan to pre-approve Accu-Chek smartview strips. 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 plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-
preferred brands). 
 
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 Accu-Chek smartview strips. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the health plan's preferred tests strips (Ascensia/Bayer products 
(for example, Contour Next) or OneTouch products (for example, OneTouch Ultra 2/Verio)) would not be 
sufficient in meeting your medical 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 Accu-Chek smartview strips have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Accu-Chek smartview strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says POS 81 is not applicable. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 laboratory services provided to the enrollee on June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vitrectomy chair obtained on March 1, 2021. 
 
You asked the Plan to pay for a vitrectomy chair. You say that a vitrectomy chair was necessary after eye 
surgery and was ordered by your doctor. The Plan denied your request. The Plan says you did not have prior 
authorization for this equipment and this chair is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover precautionary equipment or 
self-help devices. The Plan contract states durable medical equipment may require prior authorization. You did 
not have prior authorization and this equipment is precautionary in nature and is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for a vitrectomy chair obtained on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. 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 the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee's record indicates chronic obstructive pulmonary disease (COPD), but there are no 
pulmonary function tests to support the diagnosis, and the enrollee has never smoked, so COPD seems 
unlikely.  Overnight oximetry on oxygen shows some desaturations and a few brief periods of elevated end-
tidal CO2 (ETCO2), consistent with obstructive sleep apnea (OSA). There is no arterial blood gas analysis 
(ABG), done while stable as an outpatient, to document CO2 retention. This enrollee does not have thoracic 
restrictive disease, neuromuscular disease, or evidence supporting COPD with chronic hypoventilation. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 13, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code is not supported in the medical records submitted. 
 
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 15004 is "Surgical preparation or creation of recipient 
site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of 
scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 
100 sq cm or 1% of body area of infants and children." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report does not 
include enough documentation to support surgical or creation of recipient site by excision. The procedure report describes debridement, and therefore cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services (procedure codes 99454 and 99457) provided to the enrollee on September 26, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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 the denied codes is: 
 
CPT 99454: 
 
Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow 
rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days 
 
CPT 99457: 
 Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health 
care professional time in a calendar month requiring interactive communication with the patient/caregiver 
during the month; first 20 minutes 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the review has determined that CPT 
99454 and 99457 were rendered in this case. The denied codes are not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for remote physiologic monitoring treatment management services (procedure codes 99454 and 
99457) provided to the enrollee on September 26, 2021.