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 with one power option, seat 
elevator. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with one power option, seat elevator. You say 
that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically 
necessary. 
 
  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a 
wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of 
the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 3 power wheelchair with one power option, seat elevator have not been met. Specifically, 
the power seat elevation feature is not a Medicare covered benefit. Additionally, you have requested a Group 3 
Power Wheelchair with a single power option. The power option is being requested for a power seat elevation 
feature. Because the power seat elevation feature is non-covered, the requested Group 3 Power Wheelchair 
with a single power option is not appropriate for your needs. Therefore, we decided that the Plan does not have 
to pre-approve a group 3 power wheelchair with one power option, seat elevator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim lists a place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
November 5, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that the enrollee was 
provided physical therapy treatment that she required, and the medically necessary services should be approved 
for payment. The Plan denied your request. The Plan says CPT code 99212 has been approved for payment and 
CPT code 99072 remains denied as bundled services are not eligible for separate reimbursement. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials (99072) 
have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and 
materials (99072) provided on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on May 6, 2021. 
 
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 the service should not be unbundled. 
 
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 99135 is "Anesthesia complicated by utilization of 
controlled hypotension (List separately in addition to code for primary anesthesia procedure)." 
 
We find that CPT code 99135 is not supported in the medical record. Specifically, this code has a status 
indicator of "B." This means that this code cannot be paid for separately and is always bundled into payment 
for other services not specified.  
 
 
 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 anesthesia services provided to the enrollee on 
May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
September 9, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that other patient claims 
paid for 99072 and this claim should be reprocessed for payment. The Plan denied your request. The Plan says 
bundled services are not eligible for separate reimbursement. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials (99072) 
have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and 
materials (99072) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided March 1, 2021. 
 
You asked the Plan to pay for the office visit. You say that please find the attached medical records and 
reprocess the claim. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
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 outpatient office visit (99202) provided March 1, 2021 have been met. The very limited documentation submitted the records submitted does 
not support that there was actual contact between the doctor and the enrollee. The records also indicate that the 
enrollee was unable to confirm this visit took place when contacted by the Plan. Therefore, we decided that the 
Plan does not have to pay for the outpatient office visit (99202) provided March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on August 26, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate when services are not available from preferred providers in 
the service area. You say that the in-network benefits should be honored, and the claim processed for payment. 
The Plan denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on April 13, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service should not be unbundled. 
 
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 99100 is " Anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)." 
 
We find that CPT code 99135 is not supported in the medical record. Specifically, this code has a status 
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment 
for other services not specified. 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 anesthesia services provided to the enrollee on 
April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 27, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and the rules. The claim identified the place of service as an independent laboratory. The
records provided do not show that the specimen was obtained at an independent laboratory. 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 drug testing services provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 14, 2020.
You asked the Plan to pay for the laboratory services. You say that documents are attached to process the appeal. The Plan denied your request. The Plan says the place of service must reflect the location of the patient when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We find that CPT code is not supported in the medical record. Specifically, this claim was billed with the office place of service code while the records suggest that the member's face-to-face service was rendered in a nursing facility. 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 pay for the laboratory services provided on September 14, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on October 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier 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. 
 
The file shows that CPT code 76705 was billed with CPT code 93976. We find that CPT code 76705 may be 
eligible for payment when billed with this code pair. The claim does not show that the code at issue was billed 
with a modifier suitable for payment. 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 
abdominal ultrasound provided on October 26, 2021.
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 options (K0861) and attachments for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee meets criteria for this wheelchair. The Plan denied your request. The Plan says that the member does not have need for both power tilt and power recline.
The Plan must follow Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power options can be covered if Medicare criteria has 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The patient has a Group 3 qualifying diagnosis of a neurological condition due to a stroke with hemiparesis. The documentation indicates the patient has a mobility deficit that impairs MRADLs in the home. The documentation indicates that the patient is unable to safely use a walker, cane, or manual wheelchairs due to safety issues, weakness, and history of falls. The documentation does not reveal that the patient uses a ventilator attached to a wheelchair or is at high risk for development of a pressure ulcer. She does not perform intermittent catheterization. There is no objective evidence of spasticity on a physical exam that needs a power seating system for management. For these reasons the request for power tilt and recline exceeds the patient's medical needs. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 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 Group 3 power wheelchair (PWC) with multiple power options (K0861) and attachments for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy session (90832) provided on July 19, 
2021. 
 
You asked the Plan to pay for psychotherapy. You say that these services were provided in good faith and meet 
professionally recognized standards of healthcare. The Plan denied your request. The Plan says there is no 
referring physician listed on this claim and there is no indication in the records that the servicing physician 
consulted or attempted to consult the enrollee's primary care provider prior to services. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical 
Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician 
about the provided services and document the consent or declination date to consultations and date of the 
consultations in the patients medical record. If consultations are unsuccessful, document the patients medical 
chart with the date and physician notification method. This does not apply if a physician referred the patient to 
the Clinical Psychologist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record shows that these services were rendered 
by a Clinical Psychologist. The documentation submitted does not support that this provider attempted to 
consult the members attending or primary care physician about the provided services. The records do not include a consent or declination date to consultations or the date of the consultations. A valid referral was not 
provided. Therefore, we decided that the Plan does not have to pay for the psychotherapy session (90832) 
provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 18, 2020. You asked the Plan to pay for the testing services. You say that you intended to provide the best healthcare on 
each individual specimen. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim lists a place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. 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 lab testing services provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 4, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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. The claim billed a place of service as an independent laboratory. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. 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 drug testing services provided on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on August 4, 2021.
You asked the Plan to pay for the lab services. You say that there has been a misinterpretation of guidelines. The Plan denied your request. The Plan says the billed code cannot be verified.
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. The claim information lists a place of service as an independent laboratory. The records do not show that the specimen was obtained at the independent laboratory. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on August 4, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Gammagard. 
 
You asked the Plan to pre-approve Gammagard. You say that it is medically necessary for the enrollee to 
continue receiving the requested drug. The Plan denied your request. The Plan says that the requested drug is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Gammagard. Our reviewer says that the 
requested drug Gammagard is medically necessary and reasonable for the enrollee's condition. Our physician 
reviewer found this request is for the continuation of intravenous immunoglobulin for chronic demyelinating 
polyneuropathy. In this case, the requested drug is medically reasonable and necessary because continuation 
with response warrants the continued approval of the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have been met. Therefore, we decided that the Plan has to pre-
approve Gammagard.  
 
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 imaging services provided to the enrollee on August 14, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service should not be unbundled. 
 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 93042 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on August 14, 2021.