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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee does not meet coverage criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 
 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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has COPD. There is no diagnosis 
of bronchiectasis, cystic fibrosis, or neuromuscular disease. Medicare does not cover the device for the 
treatment of COPD because the evidence to support its safety and effectiveness is inadequate. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service May 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49020 billed for date of service February 27, 
2022. 
 You asked the Plan to pay for the billed service. You say that the charges were billed on an emergent basis. The 
Plan denied your request. The Plan says the code is not payable. 
 
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 49020 is drainage of peritoneal abscess or localized 
peritonitis, exclusive of appendiceal abscess, open. We find that CPT code 49020 is not supported in the 
medical record. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 49020 billed for date of service 
February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a MyoPro device. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the medical records show the enrollee had a stroke several years ago that 
affected his left arm. The device was requested to aid use of his left arm. However, there is not enough medical 
evidence that shows the MyoPro is helpful. 
 
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 a MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for him. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, 
single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter (E1399) purchased June 16, 2022. 
 
You asked the Plan to pay for the power scooter. You say that on the advice of your doctor, you purchased a 
mobility scooter. You then called the Plan and was told how to file a claim. You were told that this was denied 
because the requested information from the doctor was not forwarded but you did send in the doctor's letter. 
The Plan denied your request. The Plan says the provided records do not show that you meet the Medicare 
criteria for the requested power operated vehicle. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the letter from the doctor submitted, was written 
on August 19, 2022, which is after you purchased and received the power scooter. Also, there was no physician 
signed seven element order, face to face examination with your provider, physician signed detailed product 
description order, physical/occupational therapy assessment, or home assessment provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the power scooter (E1399) purchased June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code 99070. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 2022. 
 
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 procedure code 87801 is 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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the documentation shows 
four separate forms of enterobacter with four separate results, not group testing. 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 laboratory services rendered on August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87591, 87491, 87481, 87798 
provided August 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim has been denied but the listed 
services were not requested by your provider. The Plan denied your request. The Plan says requested records 
was not received from the provider. 
 
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 the laboratory services have been met. 
medical records was needed to support the medical necessity of the tests. The record show that the Plan made 
multiple attempts to obtain medical records from the provider without success. Therefore, we decided that the 
Plan does not have to pay for the laboratory services coded as 87591, 87491, 87481, 87798 provided August 2, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88360 and 88381 billed for date of service 
February 23, 2022. 
 You asked the Plan to pay for procedure codes 88360 and 88381. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says these codes are included in the facility payment and are 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 codes 88360 and 88381. This 
means there is both a professional and technical component for the CPT codes. In this case, an appropriate 
modifier to indicate the professional component has not been billed with CPT codes 88360 and 88381. Based 
on this information, we decided that Medicare rules for coverage of procedure code 88360 and 88381 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88360 and 88381 billed 
for date of service February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
April 26, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 heavy-duty, patient 
weight capacity 301 to 450 pounds (K0801) and a wheelchair component or accessory, not otherwise specified 
(K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessory. You say that you need the requested 
durable medical equipment to be able to get around as you are unable to drive. You also say that you are an 
active person and staying at home gives you depression and cause pain in your hips. The Plan denied your 
request. The Plan says the request is not medically necessary because your records show you do not have 
mobility limitation that cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or 
walker. 
 
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 a power wheelchair and accessory. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not indicate that you are unable to perform MRADLs in the home. The documentation does not indicate 
that you are unable to use a manual wheelchair. The PT notes indicate that you are making progress with a 
walker and could ambulate 200 feet with standby assist. The documentation notes on 10/19/2022 show that you 
get disoriented and have cognitive deficits. The documentation is not clear that you can safely use the power 
operated vehicle. 
 
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 power wheelchair and accessory have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power operated vehicle, group 1 heavy-duty, patient weight 
capacity 301 to 450 pounds (K0801) and a wheelchair component or accessory, not otherwise specified 
(K0108).
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 July 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
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 July 6, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 17, 2022 to 
March 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 17, 2022 to 
March 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
August 2, 2022. 
 
You asked the Plan to pay for the 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. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
 We find that CPT code 99223 is not supported in the medical record. Specifically, this procedure is included in 
an outpatient claim previously processed by the Plan on August 12, 2022. Based on this information, we 
decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we 
decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on August 
2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs to stay in the skilled nursing 
facility until other arrangements can be made. The Plan denied your request. The Plan says the medical records 
indicate the enrollee's medical condition has been stable and the request for approval of continued admission in 
skilled nursing facility (SNF) does not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 18, 2022, billed with 
codes 81162, 81201, 81249, 81292, 81295, 81298, 81317, 81321, 81351, 81404, 81406, 81325, 81408 and 
81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported as 
billed. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the 
claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 18, 2022, billed with codes 81162, 81201, 81249, 81292, 81295, 81298, 81317, 81321, 81351, 81404, 
81406, 81325, 81408 and 81272.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial 
surgery (95955) provided on December 21, 2021. 
 
You asked the Plan to pay for the EEG. You say that you would like this claim to be reprocessed for payment. 
The Plan denied your request. The Plan says experimental or investigational services are not covered. 
 
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 the EEG. Our reviewer says that the EEG is 
not considered medically reasonable and necessary in this case. Our physician reviewer found in this case a two 
channel EEG was performed. The limited number of channels recorded falls well below the minimum 
requirements set forth by the guidelines. Our reviewer also found that such evaluation during a lumbar spine 
procedure has not been shown to have any impact on surgery or surgical outcomes. 
 
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 EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for the electroencephalogram (EEG) during non-intracranial surgery (95955) provided on December 21, 
2021.