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

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on April 4, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 0037U is not supported in the medical record. Specifically, the date the specimen was 
collected (March 10, 2022) does not match the date of service billed. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic testing (0037U) provided on April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reduction mammaplasty (19318). 
 
You asked the Plan to pre-approve the procedure. You say that you are appealing the denial because you need 
this procedure. The Plan denied your request. The Plan says the records do not support that requested procedure 
is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
 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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer 
found in this case, the record indicates that the enrollee has macromastia. The record provided indicates that the 
enrollee has had previous breast reduction. The provided record does not indicate failure of conservative 
therapy for the intertrigo. The records indicate that the plan is to remove 550g from each breast of the enrollee 
who has a body surface area of 2.09 meters squared. This amount is less than is listed in the Schnur scale. The 
elements of the coverage criteria are not satisfied.  The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve reduction mammaplasty (19318).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0202U provided on May 8, 2022. 
 
You asked the Plan to pay for procedure code 0202U. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0202U is a non-covered service/code. 
Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen panel have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0202U provided on 
May 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99204 billed for date of service February 3, 2022. 
 
You asked the Plan to pay for code 99204. You say that these services were medically necessary. The Plan 
denied your request. The Plan says code 99204 is inappropriate for the services rendered. 
 
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 99204 is New patient office visit, 45-59 minutes. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, you billed for a new patient 
office visit.  However, records show that this patient had previously been seen by this provider on June 24, 
2021.  As such, the patient was not a new patient, so a different code should have been used for the visit on 
February 3, 2022. Based on this information, we decided that Medicare rules for coverage of code 99204 have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99204 billed for date of service 
February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says they exclude coverage for out-of-network service. 
 
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 an office visit provided on March 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a group 3 power wheelchair and accessories. 
 
You asked the Plan to pay for the wheelchair and accessories. The Plan denied your request. The Plan says this 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the wheelchair and accessories. Our 
reviewer says that the requested group 3 power wheelchair and accessories are not medically reasonable and necessary. Our physician reviewer found that the enrollee does not have myopathy. The enrollee does not have 
a congenital skeletal deformity. The documentation is not clear that the enrollee has a neurological condition 
that requires a Group 3 Wheelchair. The enrollee has lower extremity weakness, but there is no documentation 
of an actual spinal cord injury. There is no clear spinal cord level documented. The physician progress note 
indicates medical history as - constipation, hypertension, fatty liver, cervical spine surgery, hyperlipidemia, 
obesity, neck swelling, PAF, thalassemia, and Type 2 DM. It is not clear if this weakness is from chronic 
radiculopathy or the specific details of the weakness that would indicate there is a Group 3 qualifying diagnosis 
for a power wheelchair. 
 
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. As the power wheelchair in this case is not 
medically necessary, the requested accessories are also not covered. Therefore, we decided that the Plan does 
not have to pay for a group 3 power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology (cutaneous melanoma), mRNA, gene 
expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-
fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph 
node metastasis (CPT code 81529). 
 
You asked the Plan to pre-approve the laboratory services. You say that it is medically necessary for the 
enrollee's cancer treatment plan. The Plan denied your request. The Plan says your request is not medically 
necessary because the enrollee's records show they do not have documentation of concern about adequacy of 
micro staging of this new lesion. 
 
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 laboratory services. Our physician 
reviewer found the records show the enrollee does not have documentation of concern about adequacy of micro 
staging of this new lesion. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time 
RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, 
algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis (CPT code 
81529).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88120) provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this test was for screening purposes and is non-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, genetic 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 lab 
services (88120) provided on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot drop splint x2 to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve foot drop splint x2. You say that you do not want to go to an in-network 
provider, you have obtained DME with the OON vendor in the past. The Plan denied your request. The Plan 
says the service can be provided by an in-network provider. 
 
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 
foot drop splint x2 to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87641, 88305 and 88312) billed 
for date of service August 26, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says insufficient documentation was provided to support these 
services as necessary and billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, no medical records were provided to support these services as billed. In addition, no progress note 
or medical records from the ordering physician were included, and it is unclear if these services were medically 
necessary and met Medicare rules. Therefore, we decided that the Plan does not have to pay for laboratory 
services (87798, 87641, 88305 and 88312) billed for date of service August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (procedure codes G0402, G0463) 
provided to the enrollee on February 18, 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 per Medicare guidelines, two evaluation and management codes billed with the same revenue 
code on the same date of service must billed with condition code G0. 
 
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 procedure codes G0402 and G0463 are not supported in the medical record. Specifically, in this situation, condition code G0 would need to be appended to this claim. 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 outpatient services (procedure codes G0402, G0463) provided to the enrollee on February 
18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision of total shoulder arthroplasty, including 
allograft when performed, humeral and glenoid component (23474). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the records support the necessity of the 
service in dispute. 
 The Plan denied your request. The Plan says the request service is not supported by the documentation as the 
procedure that will be performed. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee was being treated for primary osteoarthritis of the right shoulder. The 
enrollee presented with continued increased pain and a worsening burning sensation. The exam of the right 
shoulder reveals minimal erythema. No evidence of infection. X-rays were noted to show bony changes 
consistent with chronic infection. 
 However, detailed documentation is not evident regarding that the treating providers plan was for a revision of 
the reverse total shoulder arthroplasty. The provider noted the treatment plan included the removal of right 
reverse shoulder replacement with spacer placement with rigorous antibiotic treatment to follow. The treating 
provider also noted (on July 15, 2022) that the enrollee has maxed out options and further surgery will result in 
loss of function. The remaining option would be a two-step revision to a hemiarthroplasty. The request does not 
appear to clearly correspond to a revision to another reverse shoulder arthroplasty, based on the record 
documentation. Therefore, the requested revision of total shoulder arthroplasty, including allograft when 
performed, humeral and glenoid component (CPT 23474), in this case, is 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revision of total shoulder arthroplasty, including allograft when performed, 
humeral and glenoid component (23474).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital services provided 
on August 5, 2020, through September 1, 2020. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says these supplies and 
services are considered routine or not supported in the medical records.  
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge--sometimes 
referred to as the "room and board" charge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Specifically, the items and services that have 
been denied by the Plan with a status code of G are considered routine and their payment is included in the 
room and board charge. The remaining denied services are not supported by the medical records. Therefore, we 
decided that the Plan does not have to pay an additional amount for the inpatient hospital services provided on 
August 5, 2020, through September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power seat options represented by code K0861 and related accessories represented by codes E1012, E2311, 
E2377, E2313, E2361x2, E1007, E1028x2, E0955, and E2607. 
 
You asked the Plan to pre-approve a Group 3 PWC with multiple power seat options and related accessories. 
You say that the records provided support the need for the requested items. The Plan denied your request. The 
Plan says the enrollee does not have a medical need for multiple power options included with the K0861 Group 
3 PWC. 
 
The Plan follows Medicare rules. Medicare rules say that Group 3 PWCs with multiple power options are 
covered for certain medical indications. Medicare rules also say that if the PWC base is not covered, then 
related accessories will be denied. 
 
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 Group 3 PWC with multiple power 
seat options and related accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the documentation indicates the enrollee has a mobility deficit that impairs MRADLs 
in the home and is not ameliorated by a walker, cane, manual wheelchair due to weakness and contractures. 
While the enrollee may be able to safely operate a powered mobility device (PMD) the requested K0861 with 
multiple power options exceeds the enrollee's medical need. The enrollee does have a Group 3 qualifying 
neurologic diagnosis, but the documentation does not reveal that the enrollee needs is at high risk for 
development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power 
seating system to manage increased tone or spasticity. 
 
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 Group 3 PWC with multiple power seat options and related accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair 
(PWC) with multiple power seat options represented by code K0861 and related accessories represented by 
codes E1012, E2311, E2377, E2313, E2361x2, E1007, E1028x2, E0955, and E2607.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is still weak, and she currently lives 
alone and cannot be discharged her daily life is at risk. The Plan denied your request. The Plan says this is not 
medically necessary, and the enrollee can safely receive the services they need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heated humidifier provided on May 26, 2022, by an OON 
provider. 
 
You asked the Plan to pay for a heated humidifier. You say that previous dates were paid without authorization. 
The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 a heated humidifier provided on May 26, 2022, by 
an OON provider.