Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for DCISionRT testing (0295U) provided on July 14, 2022. 
 
You asked the Plan to pay for DCISionRT testing. You say that this testing is medically necessary and is not 
experimentation/investigational. The Plan denied your request. The Plan says that this testing 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 pay for DCISionRT testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found DCISionRT provided information that significantly changed the recommendations to add or 
omit RT. Compared with traditional clinicopathologic features used to determine recommendations for or 
against RT, the factor most strongly associated with RT recommendations was the DCISionRT result, with 
other factors of importance being patient preference, tumor size, and grade. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DCISionRT testing have been met. Therefore, we decided that the Plan has to 
pay for DCISionRT testing (0295U) provided on July 14, 2022.  
 
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 Avise CTD test panel (0312U) provided May 25, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the Avise CTD test panel is 
considered experimental and investigational, as it is unproven to alter disease prognosis or treatment outcomes 
and has not been proven to be superior to alternative tests and measures of disease activity. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Avise CTD test panel (0312U) provided May 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from 
January 14, 2023, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that you need continued SNF care to improve 
mobility. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because 
you no longer require skilled services on a daily inpatient basis, and the continuation of SNF is not medically 
necessary.  
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 continuation of SNF care from January 14, 2023, forward is not considered medically reasonable and 
necessary based on Medicare guidelines. Our physician reviewer found that 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 skilled nursing facility (SNF) care from January 14, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on September 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study 
coded 95927 provided on March 11, 2022. 
 
You asked the Plan to pay for the short-latency somatosensory evoked potential study. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed 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 95927 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. 
 We find that CPT code 95927 is not supported in the medical record. Specifically, the submitted medical 
records do not support that short-latency somatosensory evoked potential (SSEP) study, stimulation of any/all 
peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head was performed. 
Based on this information, we decided that Medicare rules for coverage of the short-latency somatosensory 
evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the 
short-latency somatosensory evoked potential study coded 95927 provided on March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies and lead wires provided on 
June 20, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies and lead wires. You say that you are appealing 
the denial with submitted medical records for review. The Plan denied your request. The Plan says proof of 
delivery is required, the documentation submitted does not include valid proof of delivery, therefore payment is 
not supported at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that for any items that do not have proof of delivery 
from the supplier, such claimed items shall be denied. 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator supplies and lead wires have not been met. Therefore, we decided that the 
Plan does not have to pay for electrical stimulator supplies and lead wires provided on June 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 76000 billed for date of service 
June 8, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 76000. The Plan denied your request. The Plan says 
procedure codes 20930 and 76000 are 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 code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 20930 have not been met. 
 
In this case, we have confirmed that code 76000 is a column II code to column I code 22551. 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 20930 and 76000 billed for date of service June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared light therapy provided on June 8, 2022. 
 
You asked the Plan to pay for infrared light therapy. You say that the services performed were medically 
necessary. The Plan denied your request. The Plan says infrared therapy is considered not reasonable and 
necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). 
 
We looked at the file and Medicare rules. Medicare says say that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we 
decided that the Plan does not have to pay for infrared light therapy provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and diagnostic radiology services provided on 
August 8, 2022. 
 
You asked the Plan to pay for the office visit and diagnostic radiology services. You say that the provider is in-
network and no authorization is needed. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit and diagnostic radiology services provided on 
August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 30, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99222.  
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 99497 
is a column II code to column I code 99222. 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 99497 billed for date of service July 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 15, 2022, 
to May 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 15, 2022, to 
May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514). 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee had an MRI (magnetic 
resonance imaging) done on November 17, 2022. The Plan denied your request. The Plan says the requested 
service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous augmentation is indicated in acute and 
subacute vertebral compression fractures. 
 
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 surgical service. Our reviewer says 
that the surgical service is not medically necessary. Our physician reviewer found percutaneous augmentation is indicated in acute and subacute vertebral compression fractures. The reviewer found that the provided 
documentation indicates this fracture is chronic, as it is mentioned in December 2020.  Therefore, the reviewer 
found that the requested surgical service 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services and glucose blood test provided on March 
15, 2022, identified with codes 82962, 41899, 41874, and J1100. 
 
You asked the Plan to pay for the dental services and glucose blood test identified with codes 82962, 41899, 
41874, and J1100.. You say that you feel the enrollee should be held responsible for the services rendered. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
This claim was billed with condition code 20 which has a suspend disposition per the Integrated OCE (IOCE) 
CMS Specifications manual and will be returned to the provider. Billed procedure codes were billed with GY 
modifier as a service non-covered by Medicare Statute. Therefore, as demand bill with condition code 20 was 
billed with non-covered charges per the above guidelines, the Medicare rule for reimbursement of this March 
15, 2022, claim has not been met. Therefore, we decided that the Plan does not have to pay for the dental 
services and glucose blood test provided on March 15, 2022, identified with codes 82962, 41899, 41874, and 
J1100.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex. 
 
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. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 the enrollee has a diagnosis of acute 
myeloid leukemia. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated 
for the enrollee's condition. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The services are 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 Darzalex.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73030-26-RT billed for date of service July 
6, 2022. 
 
You asked the Plan to pay for procedure code 73030-26-RT. You say that this service was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says it is not appropriate to report an unspecified, left, right or bilateral diagnosis codes when the procedure modifier on the claim line does not 
match the diagnosis code. The diagnosis codes used in this case are for an "unspecified" side; however, the 
procedure modifier is clearly for the right side. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that ICD-10 codes for "unspecified" side should rarely be used, such as when the documentation is 
insufficient to determine the affected side and it is not possible to obtain clarification. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 73030-26-RT have not been met. Specifically, the diagnosis codes submitted on 
this claim are S49.90XA (unspecified injury of shoulder and upper arm, unspecified arm, initial encounter) and 
M25.519 (pain in unspecified shoulder). These are unspecified side diagnosis codes; however, the procedure 
code modifier in this case is RT for the right side. It is not appropriate to use incompatible side diagnosis and 
procedure code modifiers, and an unspecified side diagnosis code should not be used when there is sufficient 
information to determine the affected side. Therefore, we decided that the Plan does not have to pay for 
procedure code 73030-26-RT billed for date of service July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a power wheelchair (E1399) purchased March 25, 
2022. 
 
You asked the Plan to reimburse you for a power wheelchair. You say that your son paid for the motorized 
wheelchair which has been an instrumental help in getting yourself around. With the motorized wheelchair you 
are able to reclaim some independence. The Plan denied your request. The Plan says the provided records do 
not show that you meet the Medicare criteria for the power wheelchair. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the limited records submitted includes an order for 
a motorized wheelchair on July 19, 2022, which is after the already purchased wheelchair. There was no 
physician signed seven element order, face to face examination with your provider, physician signed detailed 
product description order, physical/occupational therapy assessment, or home assessment provided. You have 
not completed the necessary evaluations for approval of any power wheelchair. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to reimburse you for a power wheelchair (E1399) purchased March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64633, 64634). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee's current pain level is 7/10. You say that 
the enrollee is unable to perform daily activities on their own. You say that these services may allow the 
enrollee to continue with a physical therapy program and avoid or delay surgery. The Plan denied your request. 
The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region, no more than two 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
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 RFA. Our reviewer says that the 
requested RFA is not medically necessary. Our physician reviewer found the provided documentation indicates 
that the enrollee has already had two cervical region RFA's in the past 12 months. Therefore, the reviewer 
found that the injections 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64633, 64634).