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

 
We decided that the Plan does not have to pay for self-administered drugs (A9270) provided on January 6, 
2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that these services should be covered. The 
Plan denied your request. The Plan says self-administered drugs provided in the outpatient setting are not 
eligible for Part B coverage. 
 
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 pay for self-administered drugs (A9270) 
provided on January 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from June 24, 2022, to June 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed without a clinical trial number. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service on or 
after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in 
clinical trials/studies/registries, or under CED.  
 
We looked at the file and Medicare rules. The claim was billed without a valid clinical trial number as required 
by 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 provided from June 24, 
2022, to June 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 86077. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroplasty (CPT code 0201T). 
 
You asked the Plan to pre-approve the sacroplasty. You say that the surgery is necessary. The Plan denied your 
request. The Plan says there are not enough studies on sacroplasty to show it is safe and effective. 
 
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 sacroplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found sacroplasty is experimental for sacral insufficiency fractures. 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 sacroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
sacroplasty (CPT code 0201T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve balloon dilation of the eustachian tube procedure 
(bilateral). 
 
You asked the Plan to pre-approve balloon dilation of the eustachian tube procedure (bilateral). You say that 
balloon dilation of the eustachian tube procedure (bilateral) is medically necessary. The Plan denied your 
request. The Plan says balloon dilation of the eustachian tube procedure (bilateral) 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 balloon dilation of the eustachian tube 
procedure (bilateral). Our reviewer says that the requested balloon dilation of the eustachian tube procedure 
(bilateral) is not considered medically reasonable and necessary. Our physician reviewer found that in this case, 
the record indicates that the enrollee has pulsatile tinnitus. There is insufficient literature to support the safety 
and efficacy of the requested service for the enrollee's specific condition. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of balloon dilation of the eustachian tube procedure (bilateral) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve balloon dilation of the eustachian tube 
procedure (bilateral).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99213, 99204) provided from February 17, 
2022, to March 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
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 payment for CPT codes 99213 and 99204 is not supported in the medical record. Specifically, 
these codes are assigned status indicator B under the OPPS, which means these codes are not recognized and not payable under OPPS. 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 (99213, 
99204) provided from February 17, 2022, to March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service June 14, 
2022. 
 
You asked the Plan to pay for procedure code 99024. The Plan denied your request. The Plan says procedure 
code 99024 is 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 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99024 billed for date of service June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 20930. You say that the service was medically necessary. The 
Plan denied your request. The Plan says procedure code 20930 is considered bundled and 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 code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service June 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eleven home health nursing visits and seventeen home 
health aide visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says it cannot be said where additional visits are medically indicated. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found that there are no 
documented skilled nursing needs (IVs, complex wound care, new ostomy, new tube feeds) or skilled therapy 
needs. As such, the home health services including the associated aide services are not shown to be 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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve eleven home health nursing visits and seventeen home health aide visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an automatic defibrillator. 
 
You asked the Plan to pre-approve implantation of an automatic defibrillator. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of an automatic defibrillator is 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 implantation of an automatic 
defibrillator. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. There have been no sustained ventricular tachyarrhythmias. Review of 
clinical documents does not show that the enrollee meets implant criteria for defibrillator insertion according to 
current guidelines. In the absence of such documentation, implantation of an automatic defibrillator would not 
be considered medically necessary in the management of this enrollee. Our physician reviewer found the 
enrollee has non-sustained ventricular tachycardia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of an automatic defibrillator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of an automatic defibrillator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Medicare guidance says non-injectable, self-administered drugs like Trulicity are 
covered by the pharmacy (drug) benefit. 
 
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 Trulicity injection.   
Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Orthovisc. 
 
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 Orthovisc. Our reviewer says that the 
enrollee does not meet criteria for the requested Orthovisc. Our physician reviewer found the records show 
imaging studies of the knee that show only mild degenerative joint disease. Also, there is a previous visco 
injection without documentation of functional improvement degree and pain relief amount. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the codes were billed 
without the appropriate modifier. 
 
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 payment for CPT code 73010 and 73030 is not supported in the medical record. Specifically, these 
codes were billed without the appropriate anatomic modifier. 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 provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80050, 80061, 36415, 84480, 84439) 
provided on February 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim paid. The Plan denied 
your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until May 10, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services (80050, 80061, 36415, 84480, 84439) provided on February 10, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ForeSee Home monitoring device (0379T). 
 
You asked the Plan to pre-approve the ForeSee Home monitoring device. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this item is experimental and non-covered. 
 
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 ForeSee Home monitoring device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Foresee Home monitoring program is considered investigational as 
additional clinical studies are needed to demonstrate that it affects visual outcomes. 
 
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 ForeSee Home monitoring device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a ForeSee Home monitoring device (0379T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 94761. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says procedure code 94761 is considered bundled and 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 94761 has a status indicator of T on the Physician Fee Schedule. There was 
another payable service billed on the same date by the same provider (code 99204) This means that procedure 
code 94761 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 94761 billed for date of service April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the preparatory prosthesis (CPT code(s): L5530, L5618, 
L5632, L5634, L5661, L5910, L5971, L5986 and L8420). 
 
You asked the Plan to pre-approve the prosthesis and other accessories.. You say that the prosthesis is 
necessary. The Plan denied your request. The Plan says this exceeds the enrollee's need. 
 
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 prosthesis and other accessories. 
Our physician reviewer found the L5530 Patella tendon bearing socket and the L5910 exceed the enrollee's 
medical need as the enrollee has a Syme amputation and does not have a transtibial amputation. As the base 
code is not approved the additional requested components are not medically necessary per Medicare's LCD: 
Lower Limb Prostheses (L33787) and Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 
411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.  
 
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 prosthesis and other accessories. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the preparatory prosthesis (CPT code(s): L5530, L5618, L5632, 
L5634, L5661, L5910, L5971, L5986 and L8420).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the peripheral angiography of right lower extremity 
(RLE) (CPT code(s): 37224, 37228, 37229, 37225). 
 
You asked the Plan to pre-approve the service. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary for the enrollee's condition. 
 
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 service. Our physician reviewer 
found there is insufficient documentation to support the percutaneous transluminal angioplasty (PTA) in this 
enrollees clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the peripheral angiography of right lower extremity (RLE) (CPT code(s): 37224, 37228, 
37229, 37225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 93882 billed for date of service June 29, 
2022. 
 You asked the Plan to pay for procedure code(s) 93882. 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 this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 93882. 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) 93882. Based on this information, 
we decided that Medicare rules for coverage of procedure code 93882 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 93882 billed for date of service June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99202) provided to the 
enrollee on May 18, 2022. 
 
You asked the Plan to pay for the services. You say that G63 is a valid, billable, and payable diagnosis. The 
Plan denied your request. The Plan says a manifestation code was the primary, first-listed, or principal 
diagnosis 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 99202 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and straightforward medical decision making. When using time for code selection, 15-29 minutes 
of total time is spent on the date of the encounter." 
 
We find that CPT code 99202 is not supported in the medical record. Specifically, G63 is not appropriate use as 
a primary diagnosis, as it has a code-first note. 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 an 
office visit (procedure code 99202) provided to the enrollee on May 18, 2022.