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

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 3, 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 Current Procedural Terminology (CPT) code 83789-59 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
In this case, the CPT Code Manual definition of code 83789 is "Mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen."  
We find that CPT code 83789 is not supported in the medical record. The services at issue in this case are for 
the purpose of specimen validity testing. 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 May 3, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation services provided to the enrollee from October 1, 
2021, to October 2, 2021, and billed under code G0378. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says payment for these services was packaged into the other codes previously paid for these 
services. This claim cannot be billed separately.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to 
its code relationship to services previously paid. Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for observation services provided to the enrollee 
from October 1, 2021, to October 2, 2021, and billed under code G0378.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (procedure code 76946) provided to the enrollee 
on October 6, 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 is bundled to another code. 
 
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 76946 is "Ultrasonic guidance for amniocentesis, 
imaging supervision and interpretation." 
 
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 procedure report does not 
document that an amniocentesis was performed. 
 
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 the services (procedure code 76946) provided to the enrollee on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging and biopsy services provided to the enrollee on 
August 27, 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 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 the denied codes is: 
 
CPT 55700: 
 
Biopsy, prostate; needle or punch, single or multiple, any approach 
 
CPT 76498: 
 
Unlisted magnetic resonance procedure (eg, diagnostic, interventional)  
CPT 76872: 
 
Ultrasound, transrectal 
 
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 there is a pathology report showing a 
diagnosis of prostate cancer from a sampling done on 8/27/21; however, there is no description of the 
techniques including magnetic resonance imaging and ultrasound to support the billed codes. 
 
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 imaging and biopsy services provided to the enrollee on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, pilot cushions, and an 
electronic connection. 
 
You asked the Plan to pre-approve an expandable controller, harness, pilot cushions, and an electronic 
connection. You say that the items 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 expandable controller, harness, pilot 
cushions, and an electronic connection. Our reviewer says that the items are not medically necessary. Our 
physician reviewer found the expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504). The enrollee does not require non-proportional 
input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for 
alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer 
through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and 
power elevating leg rests but the patient does not need to control the power options through a joystick. The 
patient's upper extremity function with independence in feeding supports that the enrollee can control any 
power options through their own switches. 
 
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 expandable controller, harness, pilot cushions, and an electronic connection 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, 
harness, pilot cushions, and an electronic connection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 4 home health skilled nursing visits. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 4 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health 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 4 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 4, 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 14021: 
 
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm 
 
CPT 64864: 
 
Suture of facial nerve; extracranial 
 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 in terms of CPT 14021, the 
operative report does not describe an adjacent tissue transfer. The operative report documents "this left a defect 
that required advancement of the frontalis muscles and inset with interrupted 3-0 Monocryl 
sutures." "Advancement of the frontalis muscles" cannot be verified as an adjacent tissue transfer. Of note, this 
procedure cannot be verified if more than a simple closure, and therefore would be inclusive to the mass 
excision. In terms of CPT 64868, this procedure would inclusive to the primary code, and not reported 
separately. 
 
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 March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided to the enrollee 
on October 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should paid for. The Plan denied your request. The 
Plan says an appropriate modifier was not billed on the claim to indicate the code as not included to the global 
period of the minor surgical procedures. 
 
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 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 We find that CPT code 99232 is not supported in the medical record. Specifically, this code should not be 
reported separately when it is within the global period of the surgery. 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 evaluation and management services provided to the enrollee on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aqualift bath lift. 
 
You asked the Plan to pre-approve aqualift bath lift.. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve aqualift bath lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 11, 
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 code cannot be verified. 
 
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 52330 is "Cystourethroscopy (including ureteral 
catheterization); with manipulation, without removal of ureteral calculus." 
 
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 operative report describes a 
cystourethroscopy with manipulation, however, this procedure would be inclusive to the cystourethroscopy 
with ureteroscopy and/or pyeloscopy.  
 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 October 11, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850. 
 
You asked the Plan to pre-approve GenVisc 850. 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. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 GenVisc 850. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug 
Durolane, Gelsyn-3 and Synvisc/Synvisc-One before they will approve the requested drug. In this case, you 
have not tried and failed the required drug(s). There is no documentation provided indicating that the Plans 
required drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GenVisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GenVisc 850.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on April 4, 
2021. 
 
You asked the Plan to pay for the services. You say that the providers are different specialties and does not 
exceed the maximum number of hours. The Plan denied your request. The Plan says the exact same service was 
already billed for this patient and date of service. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, this code can only be used 
once per date of service. It has already been paid for. 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 critical care services provided to the enrollee on April 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 7, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no documented result of 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 there is clinical utility for SelectMDx in males 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 June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient psychotherapy services provided to the enrollee on 
August 10, 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 provider must attempt to consult the attending or primary care physician about the services 
furnished and document the consent or declination date to consultations, and the date of consultations in the 
patients medical record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
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, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for outpatient psychotherapy services provided to the 
enrollee on August 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on October 13, 2021, and October 26, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee needed to be transported and monitored due to altered mental status, dementia with behavior 
disturbances, and a danger to self and others. You also say that the enrollee had become increasingly aggressive 
with other residents and needs monitoring. The Plan denied your request. The Plan says this service is not 
covered. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the non-emergency ambulance transportation and 
ground mileage was not medically reasonable and necessary. Our physician reviewer found the record does not 
indicate that the patient's clinical condition is such that other methods of transportation, such as stretcher van, 
were contraindicated. Our reviewer found that the elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested service cannot be recommended. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on October 13, 2021, and October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 21, 
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 services were not supported by the medical records. 
 
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 21, 2021.