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

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vertical shock 
reducing pylon feature (L5988), an all-lower extremity prosthesis, foot, flexible keel (L5972) and an all 
endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability (L5984). 
 
You asked the Plan to pre-approve prosthetics. You say that the leg and part of the foot was approved, but one 
code in the foot was denied. We need approval for both codes in order to provide the foot for the enrollee. She 
is a K2 amputee, and the requested foot is a K2 foot. You would like all included documents reviewed to see 
that the code should be covered and overturn the denial, allowing the enrollee to walk again. The Plan denied 
your request. The Plan says the request for one foot and ankle and shock reducing pylon cannot be approved at 
this time by Medicare or the health plan. The enrollee may meet criteria for a simpler foot and ankle. 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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the vertical shock reducing pylon addition to a prosthesis is for the enrollees with vigorous 
activity. The enrollee is a K2 ambulator who does self-care and household chores. The record does not indicate 
the enrollee engages in vigorous walking or stressful activities for her legs. The records also do not provide 
evidence the requested addition is 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 prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988), an all-
lower extremity prosthesis, foot, flexible keel (L5972) and an all endoskeletal lower extremity prosthesis, axial 
rotation unit, with or without adjustability (L5984).
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 May 10, 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 May 10, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) system 
(64555). 
 
You asked the Plan to pre-approve the Sprint peripheral nerve stimulator. You say that the denial for this 
procedure is unwarranted and unsupported. The Plan denied your request. The Plan says the Sprint peripheral 
nerve stimulator system does not fit the Medicare definition of implanted peripheral nerve stimulator. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the Sprint peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Sprint peripheral nerve stimulator (PNS) system (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic knee component described by code L5845 
(in addition to L5812 which was approved). 
 
You asked the Plan to pre-approve the knee component coded as L5845. You say that the prosthetic leg should 
be approved with all requested codes. The Plan denied your request. The Plan says L5845 cannot be approved 
in addition to L5812 as this would 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, the Code Manual definition of code L5845 is Addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable. The approved code L5812 is defined as Addition, endoskeletal knee-shin system, 
single axis, friction swing and stance phase control (safety knee).  
 
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 pre-approve the knee component coded as L5845. Our reviewer says 
that the requested use of code L5845 is not supported. Our reviewer found the function described by L5845 is 
included in the functionality of code L5812. Therefore, it would be inappropriate to approve L5845, in this case. 
 
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 knee component coded as L5845 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a prosthetic knee component described by code L5845 (in addition 
to L5812 which was approved).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray (CPT code 73562) and therapeutic, 
prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (96372) 
provided on August 5, 2022. 
 You asked the Plan to pay for the 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code [Enter billing code at issue (e.g. 43856, K0002, etc.)] is not supported in the medical 
record. The billed procedure code 73562-RT has a physician Fee Schedule PCTC indicator of 1 and the claim a 
POS of 23  Emergency Room- Hospital. The professional interpretation was furnished in the same payment 
locality from where the TC was furnished. The Medicare rule for payment of this claim has not been met as the 
professional interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting 
physician. CPT code 96372-59 has a PC/TC indicator of Five (5) and Payment may not be made by carriers for 
these services when they are provided to hospital inpatients or patients in a hospital outpatient department as 
defined in Medicare Claim Processing Manual Chapter 23, in the 50.6 - Physician Fee Schedule Payment 
Policy Indicator File Record Layout. A review of the claim image shows provider billed POS of 23  
Emergency Room- Hospital; therefore, we find the Medicare rule for payment of this claim has not been met. 
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 the knee x-ray (CPT code 73562) and therapeutic, 
prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (96372) 
provided on August 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TENS supplies provided on June 12, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says there is evidence of 
misrepresented services. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is covered for chronic, intractable pain 
other than chronic low back pain.  
 
We looked at the file and Medicare rules. LCD L33802 states that TENS and related supplies are covered for 
chronic pain other than low back pain. The provided progress note does not document pain, but rather 
weakness. TENS supplies are not covered for weakness. Based on this information, we decided that Medicare 
rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the TENS supplies provided on June 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis provided on July 28, 2022. 
 
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says there is evidence of 
misrepresented services. 
 
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 orthosis have been met. The 
provided medical record does not support the diagnoses listed on the order or claim form. There is no evidence that use of an elbow brace was planned in this case. Therefore, we decided that the Plan does not have to pay 
for the shoulder orthosis provided on July 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on July 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and is 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 (81479) provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) of tooth #11 and simple 
extraction (D7140) of tooth #11 provided on May 4, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the surgical extraction and simple extraction. The Plan denied your request. The 
Plan says this service exceeds the maximum allowed per period for the procedure grouping. 
 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 surgical extraction and simple 
extraction have been met. Specifically, we find that this claim was billed incorrectly, as two extractions cannot 
be provided on the same tooth, and no records were submitted to support otherwise. If an incorrect tooth 
number was reported on the claim, a corrected claim can be submitted to the Plan. Therefore, we decided that 
the Plan does not have to pay for the surgical extraction (D7210) of tooth #11 and simple extraction (D7140) of 
tooth #11 provided on May 4, 2022, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the chest (71045) provided on November 
1, 2021. 
 
You asked the Plan to pay for the X-ray exam of the chest. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim needs to be billed to 
Traditional Medicare per hospice billing rules. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the X-ray exam of the chest (71045) provided on November 
1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for date of service October 29, 
2021. 
 You asked the Plan to pay for procedure code 99212. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99212 is bundled into payment for code G0438. 
 
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 99212 
is a column II code to column I code G0438. 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 procedure code 99212 billed for date of service October 29, 
2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services you received on April 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services you received on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radio frequency ablation (RFA) for the sacroiliac (SI) 
joint (64625) provided on July 5, 2022. 
 
You asked the Plan to pay for the RFA. You say that the records clearly demonstrate medical necessity for the 
pain management treatment. The Plan denied your request. The Plan says the requested service 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 pay for the RFA. Our reviewer says that the RFA is 
not considered medically reasonable and necessary in this case. Our physician reviewer found the RFA of the lateral sacral branches is considered experimental and investigational due to the wide variation in efficacy 
reported in the literature. Therefore, the reviewer found that the RFA is not medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pay for the radio frequency ablation (RFA) for the sacroiliac (SI) joint (64625) provided on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radio frequency ablation (RFA) (64633, 64634). 
 
You asked the Plan to pre-approve RFA. You say that the enrollee reported that the pain logs significantly 
under-represented the true amount of relief that they experienced. The Plan denied your request. The Plan says 
the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients who experience a consistent positive 
response of at least 80% relief of primary (index) pain. 
 
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 RFA. Our reviewer says that the 
requested RFA are not medically necessary. Our physician reviewer found the provided documentation does 
not indicate that the enrollee achieved 80% pain relief from each of the 2 sets of blocks. Therefore, the 
reviewer found that the requested RFA are 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radio frequency ablation (RFA) (64633, 64634).
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 June 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these tests were medically 
necessary. 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 June 6, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis (apixaban) 5 mg tablets. 
 
You asked the Plan to pre-approve the Eliquis tablets. You say that you need this medication for your heart 
condition. You need the Plan to cover this drug at a cost you can afford. The Plan denied your request. The 
Plan says this oral drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis (apixaban) 5 mg 
tablets.  
 Benefits for the Eliquis tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624), peripheral nerve block 
(64640), and ultrasonic guidance (76942). 
 
You asked the Plan to pre-approve the nerve blocks. You say that you want these services to be covered. The 
Plan denied your request. The Plan says the requested services are 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 the nerve blocks. Our reviewer says that 
the requested nerve blocks are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational and not 
medically necessary for the treatment of chronic knee pain. Therefore, the reviewer found that the requested 
services are 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 nerve blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block (64624), peripheral nerve block (64640), and ultrasonic 
guidance (76942).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 and the 
electrocardiogram coded 93010 provided on May 21, 2022. 
 
You asked the Plan to pay for the critical care services and the electrocardiogram. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. Medicare 
rules also say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the 
MAI value is 2. 
 
We looked at the file and Medicare rules. In this case, the MUE for CPT code 99291 is 1. The MAI value for 
this code is 2. One unit of this code was previously processed and paid. This means the additional units billed 
exceed the MUE. The file includes evidence that code 93010 was reimbursed by the Plan on June 8, 2022. 
Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that 
the billed items/services were provided twice on the same date. Based on this information, we decided that the 
Medicare rules for the critical care services and the electrocardiogram have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services coded 99291 and the electrocardiogram 
coded 93010 provided on May 21, 2022.