Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0859) and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the power wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says the requested items are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the provided 
medical records document a mobility deficit for which a Group 3 PWC would be indicated. However, the 
provided records do not support that the enrollee is high risk for skin breakdown, has a history of pressure 
ulcer(s), or has had skin flap surgery. The records do not document that the enrollee performs bladder self-
catheterization and is unable to transfer independently or that she has increased muscle tone or spasticity. Thus, 
the enrollee does not meet criteria for the power tilt/recline, single power option. The enrollee appears to meet 
criteria for a Group 3 PWC with no power option. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0859) and accessories.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services you received on October 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that experimental 
services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. It should also be noted that the Plan made a decision of medical necessity, but did not 
submit medical records from the contracted provider. Therefore, we decided that the Plan has to pay for the lab 
services you received on October 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a swallowing function x-ray (CPT 74230), and an upper 
gastrointestinal tract x-ray (CPT 74240) provided on October 20, 2022. 
 
You asked the Plan to pay for the swallowing function x-ray (CPT 74230), and an upper gastrointestinal tract 
x-ray (CPT 74240). You say that the services were medically necessary. The Plan denied your request. The 
Plan says the services were performed at a nursing home (via mobile van/portable x-ray), which are denied as 
an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file shows that these services were performed at a nursing home 
(via mobile van/portable x-ray) which is an excluded place of service per the Medicare LCD coverage criteria. 
Based on this information, we decided that Medicare rules for coverage of the swallowing function x-ray 
(CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240) have not been met. Therefore, we decided 
that the Plan does not have to pay for a swallowing function x-ray (CPT 74230), and an upper gastrointestinal 
tract x-ray (CPT 74240) provided on October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires and is more 
appropriate for an extended acute care. The Plan denied your request. The Plan says the enrollee's records do 
not show that you require care that can only be given in a hospital setting, when ready to leave the hospital, the 
enrollee may safely receive care in another setting, a Skilled Nursing Facility, at home with home health 
services or outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be tolerating treatment but is not yet stable for transfer and 
should only require short-term additional acute care hospital services that can safely be provided at the current 
facility until more stable and appropriate for a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Proteor Allux 2 (K1014, L5845, L5848, L5856), and 
alignable system (L5920). 
 
You asked the Plan to pre-approve the prosthetic parts. You say that the enrollee meets the definition of a 
functional level 3 amputee. You say that the enrollee's physician and prosthetist are in full agreement of the K-
3 classification and prosthetic plan of care. The Plan denied your request. The Plan says the requested 
prosthetic parts exceed the enrollee's need. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic components may be covered when the 
criteria have been 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 the prosthetic parts. Our reviewer says 
that the requested prosthetic parts are not medically necessary. Our physician reviewer found the provided documentation does not support that the enrollee is a K3 ambulator as they would like to be able to ambulate 
around the house with their prosthetics. The reviewer found that the documentation indicates that the enrollee 
can take short steps with a walker but otherwise has been using a wheelchair. The reviewer also found that the 
provided documentation does not support that the enrollee's current alignable system is damaged beyond repair. 
Therefore, the reviewer found that the requested prosthetic parts are not 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 prosthetic parts have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Proteor Allux 2 (K1014, L5845, L5848, L5856), and alignable system (L5920).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extended respiratory pathogen panel billed for date of 
service July 28, 2022, with codes U0005, U0004, 87486, 87502, 87581, 87640, 87632, 87634, 8541, 87496, 
87498, 87532, 87798, 87801 and 87503. 
 
You asked the Plan to pay for the extended respiratory pathogen panel. You say that this panel was medically 
necessary and is supported in the medical record. The Plan denied your request. The Plan says these services 
were not billed in accordance with Medicare billing guidelines. In addition, respiratory pathogen panels which 
test more than five pathogens are considered not medically necessary and reasonable. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets. Medicare rules also say that panels with more than five respiratory pathogens performed in a 
Part B outpatient setting are considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the extended respiratory pathogen panel have not been met. Specifically, this panel was unbundled 
and billed as individual components, and this panel included more than five respiratory pathogens and was 
performed in an outpatient setting. Therefore, we decided that the Plan does not have to pay for the extended 
respiratory pathogen panel billed for date of service July 28, 2022, with codes U0005, U0004, 87486, 87502, 
87581, 87640, 87632, 87634, 8541, 87496, 87498, 87532, 87798, 87801 and 87503.
Appeal type: Step-Therapy
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drug, zoledronic acid. The records do not show that the required drug would be contraindicated 
or less effective; therefore, Prolia is not reasonable or medically necessary at this time. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amounts for the Botox (J0585) injection 
(64615) provided on November 4, 2022. 
 
You asked the Plan to waive the cost share amounts for the outpatient services. You say that the billing codes 
were exactly the same for a previously claim. You also say that you are being billed more now. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance, and a $40 copayment for Medicare Part B Prescription Drugs, Physician/Practitioner Services.  
 
You have been asked to pay a 20% coinsurance for the drug and a $40 copayment for the injection. These 
services fall within the Medicare Part B Prescription Drugs, Physician/Practitioner Services benefit categories, respectively. This means that you have been asked to pay the correct amounts based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the cost share amounts for the Botox (J0585) injection (64615) 
provided on November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342 and 88360 billed for date of 
service May 9, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services were 
necessary and were reported correctly. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service May 9, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 64635 and 64636. We decided that the Plan does not 
have to pay for procedure code 99152.  
 
You asked the Plan to pay for the pain management services provided on August 8, 2022.. You say that the 
services are payable. The Plan says that the services are not separately payable. 
 
We decided that the Plan has to pay for procedure codes 64635 and 64636.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied code 64635 as the service code reflects the submitted 
codes. The Plan has not presented a clear rationale, nor did they present Medicare rules to show the denial for 
this code was valid. Code 64636 is a valid add-on code when billed with code 64635. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure codes 64635 and 64636 billed for date of 
service August 8, 2022.  
 
We also decided that the Plan does not have to pay for procedure code 99152. 
 
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 99152 
is a column II code to column I code 01940, with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99152 billed for date of service August 8, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99291. 
 
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 99497 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not payable. 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 99497 billed for date of service August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PlateletGenex Functional Defect Panel testing. 
 
You asked the Plan to pre-approve PlateletGenex testing. You say that this test is medically necessary. The 
Plan denied your request. The Plan says the requested test is not covered by Medicare. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PlateletGenex testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve PlateletGenex Functional Defect Panel testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service October 24, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service October 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array (64555). 
 
You asked the Plan to pre-approve the percutaneous implantation of neurostimulator electrode array. You say 
that the service is medically necessary. The Plan denied your request. The Plan says this service is considered 
experimental. 
 
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 percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested service is not considered medically 
reasonable and necessary in this case. Our physician reviewer found this service is considered experimental for 
chronic pain. 
 
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 percutaneous implantation of neurostimulator electrode array have not been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of 
neurostimulator electrode array (64555).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from December 16, 2021, 
to December 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the 
three Q codes (Q5001, Q5002, and Q5009). 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required G 
and Q codes. 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 pay for the home health services rendered from 
December 16, 2021, to December 31, 2021.