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

 
We decided that the Plan does not have to pre-approve utilization of the skin substitute Epifix in combination 
with the skin substitute Epicord, and the application (CPT code(S): Q4187, Q4186, 15271). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of Epifix in combination with Epicord 
in the setting of a chronic stage IV ischial wound with concerns for osteomyelitis and the presence of necrotic 
debris have not been demonstrated in the peer-reviewed literature. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Epiflex has not been documented in published literature to have utility in decubitus ulcers. It 
has been described mostly for foot and extremity ulcers. There is lack of published data to support the request. 
 
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 utilization of the skin substitute Epifix in combination with the skin substitute Epicord, and 
the application (CPT code(S): Q4187, Q4186, 15271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new power 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 the mobility limitation does not significantly interfere with the ability to perform 
activities of daily living within the home. 
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that you require a group 2 power wheelchair for mobility in the home, or to 
accomplish self-care tasks in the home. 
 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 new power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided from December 10, 2021, 
to December 11, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the billed codes. 
The Plan denied your request. The Plan says the codes remain 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 99292 is 
critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 
minutes (List separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the records do 
not indicate the time spent for each date of service. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the critical care services provided from December 10, 2021, to December 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from December 6, 2021, to 
March 7, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that you do not want to change your doctor 
since you have been visiting him since 2015. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided from December 6, 2021, to 
March 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from November 19, 2021, 
to December 9, 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 there is no valid plan of care. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims require a signed plan of care 
from the physician. 
 
We looked at the file and Medicare rules. The file shows that the submitted plan of care does not match the 
dates of service at issue. 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 November 19, 2021, to December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care services coded 99222 provided on 
January 6, 2022. 
 
You asked the Plan to pay for initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, this service was billed with 
an incorrect place of service. This service was billed with place of service 21 (inpatient hospital). Code G0378 
(hospital observation) was also billed for this date of service. The documentation does not support that the 
enrollee was inpatient for this date of service. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care services have not been met. Therefore, we decided that the Plan does not have 
to pay for initial hospital care services coded 99222 provided on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (tens) device, two 
lead, localized stimulation (E0720) provided on September 14, 2021. 
 
You asked the Plan to pay for TENS device. You say that the procedure was medically necessary. The Plan 
denied your request. The Plan says there is not enough scientific evidence to support the medical necessity of 
the following electrical stimulation as they are not shown to improve health outcomes upon technology review. 
 
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 pay for TENS device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have tried numerous interventions and medication trials. This device does not have 
adequate evidence supporting its use in painful conditions such as CRPS. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TENS device have not been met. Therefore, we decided that the Plan does not 
have to pay for transcutaneous electrical nerve stimulation (tens) device, two lead, localized stimulation 
(E0720) provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing (81455) provided on April 3, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
with incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment CPT code 81455 is not supported in the medical record. Specifically, the lab services 
should be billed with the date that the specimen was collected. The records show that the specimen was 
collected on March 23, 2022. This means that claim was billed with the incorrect date of service. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the testing (81455) provided on April 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the lab services provided on March 1, 2022. 
 
You asked the Plan to waive the copay for the testing services. You say that this is a double billing. The Plan 
denied your request. The Plan says the claim processed 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 $45 
copay for lab services at an outpatient hospital.  
 
You have been asked to pay a $45 copay for the lab services. The testing falls within the outpatient diagnostic 
tests benefit category. This means that you have been asked to pay the correct amount 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 copay for the lab services provided on March 1, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 9, 2022 billed with 
code 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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. Review of the file shows that while this was the only code on this 
claim, with multiple codes were billed on another claim but the testing was performed on the same specimen. 
This means 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 February 9, 2022 
billed with code 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on October 26, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 laboratory services (81455) provided on October 
26, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 3, 2021, to 
September 1, 2021. 
 
You asked the Plan to pay for the testing services. You say that the claim has all codes per guidelines. The Plan 
denied your request. The Plan says a required Q code was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that a Q code was not billed for each G code on the dates of service 
at issue. Based on this information, we decided that Medicare rules for coverage of the testing services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
August 3, 2021, to September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that it is impossible to continue treatment without the 
supplies. The Plan denied your request. The Plan says the documentation did not support the billed codes. 
 The Plan must follow Medicare rules. The rules state that if the information in the patients medical record does 
not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved. 
 
We looked at the file and the rules. The record does not contain relevant medical records which support 
medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the durable medical equipment provided on April 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 22, 2021 billed 
with codes 81238, 81220, 81226, 81335, 81227, 81230, 81355, 81241, 
81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 
November 22, 2021 billed with codes 81238, 81220, 81226, 81335, 81227, 81230, 81355, 81241, 
81291, and 81240.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
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 an ESI 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 chronic lumbar 
radiculopathy and pain rated at six out of 10 that worsens with standing. He had an ESI on July 21, 2022 that 
provided 80 percent pain relief reported on the follow-up office visit on August 1, 2022. Although 80 percent 
pain relief was achieved, it has not been three months from the previous ESI. The repeat ESI therefore does not 
meet the criteria for coverage and is not 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 a repeat epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (83789) provided on March 9, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and are requesting 
reconsideration of payment. The Plan denied your request. The Plan says the use of the 59 modifier is not 
supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, this code is not separately reimbursed when billed for specimen validity testing on 
specimens used for drug testing. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services (83789) provided on March 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on April 18, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that this was not an outpatient procedure. 
You say that you were not able to give yourself medications. You also say that you have paid your part of the 
bill. The Plan denied your request. The Plan says the drugs you received in the outpatient setting are considered 
self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the drugs you received are not covered under Medicare Part B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting on April 18, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 28, 2022. 
 
You asked the Plan to pay for the lab services. 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 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 the lab services provided on January 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that you need more trips for 
the year due to ongoing dialysis treatments. The Plan denied your request. The Plan says you have exhausted 
the supplemental benefit for routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
  
 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81479) provided on February 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed date of 
service is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment CPT code  is not supported in the medical record. Specifically, the lab services should be 
billed with the date that the specimen was collected. The records show that the specimen was collected on 
December 6, 2021. This means that claim was billed with the incorrect date of service. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (81479) provided on February 11, 2022.