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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 13, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that Prolia is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has osteopenia. The Food 
and Drug Administration (FDA) has not stated the drug is indicated for the enrollee's condition. The Medicare-
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The criteria for coverage are not met and the Prolia is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76642, 77066, and G0279 billed for date of 
service November 22, 2022. 
 
You asked the Plan to pay for procedure codes 76642, 77066, and G0279. You say that the claim was billed 
correctly and should be paid. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT codes 76642, 77066, and G0279 is 1. The MAI value for these codes is 2. You 
billed 2 units of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 76642, 77066, and G0279 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 76642, 77066, and G0279 billed for date of service November 
22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Flow cytometry interpretation (88189) provided May 25, 
2022. 
 
You asked the Plan to pay for the laboratory. You say that you disagree with the decision as the referring 
physician orders only the services that are needed in order to render an accurate diagnosis on behalf of the 
enrollee. The Plan denied your request. The Plan says procedure code 88189 has not met the associated 
diagnosis code relationship criteria. 
 
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 CPT code 88189 is not supported in the medical records. Specifically, the claim was billed with 
diagnosis code H05.222, edema of orbit. This diagnosis code is not listed in the Local Coverage Article as a 
covered diagnosis code that supports medical necessity. Based on this information, we decided that Medicare 
rules for coverage of the laboratory have not been met. Therefore, we decided that the Plan does not have to 
pay for the Flow cytometry interpretation (88189) provided May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the measurement of thyroid stimulating hormone (TSH) 
(84443) provided on September 15, 2022. 
 You asked the Plan to pay for the TSH testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the TSH testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
measurement of thyroid stimulating hormone (TSH) (84443) provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on May 16, 2022. 
 
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 99285-25 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 the records in this case do not 
support that there was decision making of high complexity, or that presenting problems were high severity, 
posing an immediate significant threat to life and function. The patient presented with high blood pressure and 
chest tightness suspected to be due to anxiety. The assessment after taking the history, performing an 
examination, electrocardiogram, chest imaging and laboratory testing was asymptomatic hypertension and 
anxiety. The patient was discharged to home with antihypertensive medication. The assessment was not 
consistent with a problem posing an immediate significant threat to life and function as required for high 
complexity decision making. 
 
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 emergency department services (procedure code 99285) rendered on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on April 7, 2022. 
 
You asked the Plan to pay for the physician's services. You say that this provider is not out-of-network. The 
Plan denied your request. The Plan says this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician 
services provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and have 
submitted medical records for reconsideration. The Plan denied your request. The Plan says the device does not 
meet the requirements for approval. 
 
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 ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of severe 
persistent asthma with obesity, arthritis and osteoporosis. Provided records document that the home ventilator 
is being requested for use in average volume assured pressure support (AVAPS) mode with auto-titration (AE) 
which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage 
Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the request for a home mechanical ventilator set 
in TTV-VAPS 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure consequent to chronic obstructive pulmonary disease. Provided records document that the home 
ventilator is being requested for use in targeted tidal volume - volume assured pressure support (TTV-VAPS) 
mode which could be provided by a BiPAP device with average volume assured pressure support (AVAPS) 
and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to 
provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 
reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 
93272. 
 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 93010 
is a column II code to column I code 93272. 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 93010 billed for date of service March 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has urinary incontinence 
secondary to neurogenic bladder from a stroke. This not a condition listed as covered in the Medicare rules. 
The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on April 9, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 99223 is initial hospital care, evaluation and management 
of a patient, requiring a comprehensive history, a comprehensive examination and medical decision making of 
high complexity. 
 
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 physician services. Our reviewer says that the code billed 
is not supported by the records. Our reviewer found a comprehensive history, comprehensive examination and 
high-complexity medical-decion-making must be documented. The documented history is not comprehensive. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on April 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography, extremity, unilateral, radiological supervision 
and interpretation provided to the enrollee on September 1, 2022. 
 
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 part of the primary procedure, and ineligible for separate payment. 
 
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 75710 is "Angiography, extremity, unilateral, 
radiological 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 that the documentation does not 
support the use of the code in question. CPT 75710 codes for the supervision and interpretation of an extremity 
arteriogram. This can be separately reportable from an intervention if there is no recent prior catheter-based 
angiogram or if there was a change in condition and there has to be satisfactory documentation of a diagnostic 
angiogram. CPT 37231 codes for both the intervention and angiography associated with the procedure 
including completion. In this case, there is insufficient documentation of a lower extremity angiogram to justify 
the additional charge of CPT 75710. 
 
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 angiography, extremity, unilateral, radiological supervision and interpretation provided to the 
enrollee on September 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74160 billed for date of service October 29, 
2022. 
 
You asked the Plan to pay for procedure code 74160. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74160 is bundled into payment for 
code 74177. 
 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 74160 
is a column II code to column I code 74177. 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 74160 billed for date of service October 29, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says a wheelchair cannot be authorized, and the request is denied. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is insufficient documentation indicating that the patient has the strength and 
coordination to operate the requested manual wheelchair and that her home is accessible for the requested 
manual wheelchair. Therefore, the manual wheelchair is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, Hyaluronan or derivative, Synvisc or Synvisc-
one, for intra-articular injection (codes 20610, J7325) provided on September 26, 2022.  
You asked the Plan to pay for arthrocentesis, Hyaluronan or derivative, Synvisc or Synvisc-one, for intra-
articular injection. You say that arthrocentesis, Hyaluronan or derivative, Synvisc or Synvisc-one, for intra-
articular injection was medically necessary. The Plan denied your request. The Plan says arthrocentesis, 
Hyaluronan or derivative, Synvisc or Synvisc-one, for intra-articular injection was not medically necessary. 
 
The Plan follows Medicare 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 arthrocentesis, Hyaluronan or derivative, 
Synvisc or Synvisc-one, for intra-articular injection. Our reviewer says that the requested arthrocentesis, 
Hyaluronan or derivative, Synvisc or Synvisc-one, for intra-articular injection is not medically necessary. Our 
physician reviewer found this 65-year-old enrollee was being treated for unilateral primary osteoarthritis of the 
left knee. The enrollee presented after she had a fall and landed more on her hip and has a 7-8/10 level of pain., 
which is worse with activity and the enrollee has numbness/tingling going down the left side. There is swelling. 
The exam reveals no gross deformity or malalignment. However, detailed documentation is not evident 
regarding a trial and failure of recent, reasonable, comprehensive less invasive conservative care measures for 
the left knee. Additionally, there are no diagnostic imaging studies provided to corroborate osteoarthritis of the 
left knee. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested arthrocentesis, Hyaluronan or derivative, 
Synvisc or Synvisc-one for the intra-articular injection (codes 20610 and J7325) provided on  
September 26, 2022, does meet the Medicare coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrocentesis, Hyaluronan or derivative, Synvisc or Synvisc-one, for intra-
articular injection have not been met. Therefore, we decided that the Plan does not have to pay for 
arthrocentesis, Hyaluronan or derivative, Synvisc or Synvisc-one, for intra-articular injection  
(codes 20610, J7325) provided on September 26, 2022.