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

 
We decided that the Plan does not have to pay for an ultrasound screening provided on June 14, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an ultrasound screening. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no prior authorization on file for the services 
provided. 
 
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 an ultrasound screening provided on June 14, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for dates of service December 
16, 2021, to December 17, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says this claim 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.  
 
We looked at the file and Medicare rules. The file shows that the services at issue were approved by the Plan 
on January 21, 2022, with the allowed amount being applied to your deductible. A comparison of the two 
claims shows these are exact duplicates. There is no evidence to support that the billed services were provided 
twice on the same date. A Medicare provider should accept the Medicare allowed amount as payment in full. If 
the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 billed for dates of service December 16, 
2021, to December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service January 26, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and were reported correctly. The Plan denied your request. The Plan says this code is included 
in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the enrollee did not improve initially on BiPAP but did improve on BiPAP with AVAPS. The 
enrollee would likely benefit from BiPAP with AVAPS during sleep as an outpatient. There is no evidence this 
has been tried as an outpatient. Medicare does not cover a home ventilator when used as 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
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 these services were necessary and 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 provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 15, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of a root canal obstruction on tooth #7 
(D3331). 
 
You asked the Plan to pre-approve the treatment of an obstruction. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says the treatment of a root canal obstruction (D3331) 
is not covered by your dental benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
treatment of a root canal obstruction on tooth #7 (D3331).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 
18, 2022, to September 23, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you are appealing the Plan's denial 
for your hospital stay. The Plan denied your request. The Plan says this inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found while you spent two midnights in the hospital, there is insufficient 
documentation to show that at the time of admission, it was reasonable to expect that two midnights of 
inpatient level care would be medically necessary. Furthermore, it is unknown whether your emergency 
department care crossed one midnight. Our reviewer found that as such, coverage under the two-midnight rule 
is not supported. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from September 18, 2022, to 
September 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found THE documentation shows that the enrollee has functional impairments, however no 
specific complex functional deficits and no active medical comorbidities are specified thus the complexity of 
the enrollee's documented nursing, medical and rehabilitation needs would not be expected to require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a cold therapy machine. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says cold therapy machines are 
not covered as they are considered a convenience/comfort item, not primarily medical in nature. The machine 
is considered not reasonable and necessary. 
 
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 LCD confirms the requested cold therapy machine is listed as 
not reasonable and necessary by Medicare and the Plan. Based on this information, we decided that Medicare 
rules for coverage of a cold therapy machine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto (J8499). 
 
You asked the Plan to pre-approve Xarelto. You say that the enrollee needs this medication to prevent a 
possible stroke. The Plan denied your request. The Plan says Xarelto is intended for patient self-administration. 
The Plan also says Xarelto is not covered for the enrollee's condition 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 Xarelto (J8499).  
 
  Benefits for Xarelto 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for a PCD 
have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. Because the base item E0652 cannot be covered, 
the related accessories E0656 and E0667 are also denied. Therefore, we decided that the Plan does not have to 
pre-approve pneumatic compression devices (E0652, E0656, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical (portable) ventilator. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home mechanical (portable) 
ventilator. Our reviewer says that this item is not medically necessary. Our physician reviewer found you have 
a diagnosis of COPD, although there are no pulmonary function tests to assess severity.  You have had repeated 
admissions with acute respiratory failure responding to BiPAP, but there are no ABG results provided, and no 
ABG done while stable to document chronic CO2 retention. The blood gas results provided in the record are 
venous. The hospitalization on 10/4/2022 appears to have been primarily for CHF/pulmonary edema. There is 
no diagnosis of thoracic restrictive disease or neuromuscular disease and if you do have chronic CO2 retention, 
may benefit from BiPAP with AVAPS and backup rate.  Medicare does not cover a home ventilator when used 
as 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 home mechanical (portable) ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service October 10, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 76700 is bundled into payment for code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service October 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service April 14, 
2022. 
 You asked the Plan to pay for procedure code 81345. The Plan denied your request. The Plan says payment for 
code 81345 is bundled into payment for code 0089U. 
 
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 81345 is a column II code to column I code 0089U. The code at issue 
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 
81345 billed for date of service April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 11, 2022, billed with 
codes 81321 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 11, 2022, billed with codes 81321 and 81292.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 87634 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87634 is bundled into payment for code 87632. 
 
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 87634 
is a column II code to column I code 87632. 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 87634 billed for date of service February 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve K3 microprocessor knee and foot. 
 
You asked the Plan to pre-approve K3 microprocessor knee and foot. You say that you disagree with the Plans 
denial. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that K3 prostheses are only covered for certain 
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 K3 microprocessor knee and foot. Our 
reviewer says that the documentation does not support that the requested items are medically reasonable or 
necessary. Our physician reviewer found the documentation does not support the enrollee has a K4 ambulatory 
status or that the enrollees activities need a K3 prosthesis. The enrollee currently uses a wheelchair. There is 
no evidence in the treating medical provider progress notes that a mechanical knee is unable to meet his needs 
safely and effectively. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K3 microprocessor knee and foot have not been met. Therefore, we decided that 
the Plan does not have to pre-approve K3 microprocessor knee and foot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is 
experimental/investigational. 
 
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 a MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current clinical guidelines for adult stroke rehabilitation and recovery designate robotic 
therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" 
with unproven benefit in the home environment. 
 
 
  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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).