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

 
We decided that the Plan does not have to pay for the genetic testing provided on December 15, 2021, billed 
with codes 81407, 81408, 81410, 81411, 81413, 81414 and 81442. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. 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 
December 15, 2021, billed with codes 81407, 81408, 81410, 81411, 81413, 81414 and 81442.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (E1230). 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee received a scooter 5 years ago 
and has worked out well for her, however, she is unable to take it in her car and she needs the scooter to go to 
the store, church, etc. You disagree with the denial and are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria guidelines for a power scooter as the 
scooter is approved for inside the home usage only. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (E1230).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (G6001x31). 
 
You asked the Plan to pre-approve radiation therapy. You say that the requested therapy is medically 
necessary. The Plan denied your request. The Plan says the request does not meet the Medicare or health plan 
coverage criteria. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to 
help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy of 
treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow 
reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical structures 
are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply 
to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. Certainly, using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for daily simple 
simulations (also requested in this case) and/or IGRT for a technology for which need has not been established 
by published data or supported by consensus guidelines is not necessary. The is unfavorable as billing for daily 
IGRT or daily simulations (also requested in this case) which would not be furnished in accordance with 
accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasonic guidance for placement of radiation therapy fields (G6001x31).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing services (83789) billed for date of service 
June 2, 2022. 
 
You asked the Plan to pay for validity testing. You say that the services at issue have been billed correctly for 
payment. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing services (83789) billed for date of service June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service August 31, 
2021. 
 
You asked the Plan to pay for procedure code 87634. The Plan denied your request. The Plan says payment for 
code 87634 is bundled into payment for code 87631.  
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 87631. 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 August 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that you need SNF care in order to perform daily 
activities. The Plan denied your request. The Plan says SNF benefits have been exhausted for this benefit 
period. 
 
Though the Plan follows Medicare rules, the Plan contract says that enrollees are covered for up to 120 days of 
skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level 
of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received over 120 days of SNF care during the benefit period from April 5, 2022, to 
November 6, 2022. The Plan has covered 120 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 120 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve the SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve head rest lift for queen sized bed (A9900). 
 
You asked the Plan to pre-approve head rest lift for queen sized bed. You say that you were previously 
approved for a hospital bed, but you say you do not need that yet. You have a queen mattress and just need a 
frame that will let you sit up so you can breathe. You wake up in a panic because you cannot breathe. You have 
to sleep with a lot of pillows and sit up to be able to breathe. The Plan denied your request. The Plan says the 
requested item is not covered because it is not medical in nature and is regularly and primarily used by persons 
who do not have a specific medical need for them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve head rest lift for queen sized bed (A9900).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory infectious-agent detection of 3 to 5 targets 
(87631) billed for date of service December 27, 2021. 
 
You asked the Plan to pay for a respiratory infectious-agent test. You say that the services at issue were billed 
correctly. The Plan denied your request. The Plan says the available records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87631 is: Infectious agent detection by nucleic acid 
(DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets. 
 
We find that CPT code 87631 is not supported in the medical record. Specifically, the available medical 
records indicate that the infectious-agent detection at issue had greater than 5 targets. Based on this information, we decided that Medicare rules for coverage of a respiratory infectious-agent test have not been 
met. Therefore, we decided that the Plan does not have to pay for a respiratory infectious-agent detection of 3 
to 5 targets (87631) billed for date of service December 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 pre-approve the Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or 
without adjustability (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s) (L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of 
the community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. In this case, the 
documentation doesn't support that the enrollee is a K3 level ambulator. The requested components for the 
replacement prosthesis 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 prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoskeletal knee-shin system, single axis, fluid swing and stance phase control 
(L5828), an endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) 
and an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, 
swing and stance phase, includes electronic sensor(s) (L5856).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 24, 2022, 
to March 25, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that an invalid NOA with an admission 
date of August 28, 2021, was received on January 25, 2022. Therefore, we decided that the Plan does not have 
to pay for the home health services provided from February 24, 2022, to March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service January 20, 
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 January 20, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
22, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 22, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service December 3, 
2021 to December 9, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service December 3, 2021 to December 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided March 24, 2022, to April 
22, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was submitted with the from date of March 24, 2022, representing the continued care 
in 2022. However, the claim for the 30-day period of care is submitted incorrectly with the admission date of 
July 27, 2021. Home health agencies enters a date of admission matching the from date on the first date of care 
in an admission. Therefore, we decided that the Plan does not have to pay for the home health services 
provided March 24, 2022, to April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
segmented appliance/sleeve, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and sleeve. You say that you disagree with 
the denial and are requesting reconsideration. The Plan denied your request. The Plan says the request is not 
medically necessary because the enrollee does not have lymphedema extending onto the chest, trunk and/or 
abdomen and she did not complete the four-week trial. 
 
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. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmented appliance/sleeve, full leg (E0667).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management provided on August 15, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for chronic care management. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
  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 chronic care management provided on August 15, 
2022, by an out-of-network (OON) provider.