Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97018 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 97018. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 97018 is bundled into payment for code 97016. 
 
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 97018 
is a column II code to column I code 97016. 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 procedure code 97018 billed for date of service August 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous process distraction device. 
 
You asked the Plan to pre-approve interspinous process distraction device. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 interspinous process distraction device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a diagnosis of lumbar spinal stenosis and lumbar 
radiculopathy. Interspinous process distraction devices are experimental in spine surgery. More research is 
needed. Therefore, the enrollee does not meet criteria for the requested 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 interspinous process distraction device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve interspinous process distraction device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313). 

You asked the Plan to pre-approve the upgraded electronics. You say that the requested upgraded electronics 
are medically necessary. The Plan denied your request. The Plan says that the upgraded electronics are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are necessary when there is a 
medical need to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the provided records 
document that the enrollee has 4+/5 bilateral upper extremity strength and is independent with feeding, 
grooming, and upper extremity dressing. The enrollee's wrist and hand function are rated as within normal 
limits. These assessments appear to indicate that the enrollee has adequate upper extremity strength and 
function to operate the wheelchair's power options with their own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2377, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular reeducation (97112) provided from 
August 11, 2022, through September 9, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the neuromuscular reeducation (97112) provided from August 11, 2022, 
through September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87532 and 87496 billed for date of 
service September 13, 2022. 
 
You asked the Plan to pay for procedure codes 87798, 87532 and 87496. You say that these services were 
ordered by the enrollee's treating physician and are supported as billed. The Plan denied your request. The Plan 
says these services are not supported in the medical record. 
 
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 asked our coder 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 procedure codes 87798, 87532 and 87496. Our reviewer says 
that these services are not supported in the medical record. Our reviewer found the laboratory report does not 
include documentation of Herpes virus-6 or cytomegalovirus testing, and therefore codes 87532 and 87496 
cannot be verified. In addition, the laboratory report does not support 13 units of code 87798 and does not 
specify tests to support this code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87798, 87532 and 87496 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87798, 87532 and 87496 billed for date of 
service September 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (29823) provided on November 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 29823 is "Arthroscopy, shoulder, surgical; debridement, 
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid 
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator 
cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])". 
 
We asked our coder 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 services. Our reviewer says that the use of code 29823 is 
not supported by the records provided. Our reviewer found that debridement of 3 or more discrete structures 
where no other work was performed is not documented. Therefore, this procedure cannot be verified. 
 
We looked at this coder'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 pay for the services (29823) provided on November 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion (78452), technetium tc-99m 
tetrofosmin, diagnostic, per study dose (A9502) and an injection, regadenoson (J2785). 
 
You asked the Plan to pre-approve a nuclear medicine myocardial perfusion stress test. You say that you 
regularly receive these tests, and you believe that the requested services are medically necessary. You are 
requesting reconsideration. The Plan denied your request. The Plan says the request is not medically necessary 
because there is no documentation of new, recurrent, or worsening cardiac symptoms. 
 
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 nuclear medicine myocardial 
perfusion stress test. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the reviewed documentation indicates that 
you have a diagnosis of coronary artery disease and hypertension. You had percutaneous coronary 
interventions in 2018 with stent placement in the left circumflex and right coronary arteries. Since that time, 
you have had no documented recurrence of anginal symptoms. You were last evaluated in the office for follow 
up on August 29, 2022, at which time you reported no complaints and was felt to be stable. The documentation 
indicates that you had nuclear medicine myocardial perfusion studies done in February 2021 and March 2022 
which showed normal myocardial perfusion and normal left ventricular systolic function. There is no 
documentation that you are unable to exercise. The review has determined that the requested stress test is not 
medically necessary for you. You do not meet criteria for the requested stress test. 
 
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 nuclear medicine myocardial perfusion stress test have not been met. 
Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic 
(SPECT) (including attenuation correction, qualitative or quantitative wall motion (78452), technetium tc-99m 
tetrofosmin, diagnostic, per study dose (A9502) and an injection, regadenoson (J2785).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition to lower limb prosthesis, multiaxial ankle 
with swing phase active dorsiflexion feature (L5698) and all lower extremity prostheses, flex-walk system or 
equal (L5981).  

You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says given that the enrollee is not a K3 ambulator, the requested foot cannot be 
approved. 
 
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 items. Our physician reviewer 
found the physician documentation does not support that the enrollee requires the requested K3 advanced foot 
with ankle feature. The documentation does not support given the enrollee comorbidities, current function, and 
now a bilateral amputee that the enrollee requires the requested K3 items. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5698) and all lower extremity prostheses, flex-walk system or equal (L5981).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74230 and 74240 billed for date of service 
September 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was consulted in the skilled nursing 
facility. The Plan denied your request. The Plan says the services are excluded from coverage. 
 
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 74230 is radiologic examination, swallowing function, 
with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when 
performed, contrast (e.g., barium) study. The definition of code 74240 is radiologic examination, upper 
gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when performed; single-
contrast (e.g., barium) study.  
 
We find that CPT code 74230 and 74240 are excluded from coverage as they involve contrast media. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 74230 and 74240 billed for date 
of service September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an elevated handlebar. 
 
You asked the Plan to pre-approve an elevated handlebar. You say that this is necessary. The Plan denied your 
request. The Plan says this does not primarily serve a medical purpose. This is for convenience for the 
caregiver and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an elevated handlebar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested bed is medically 
necessary for the enrollee. The Plan denied your request. The Plan says Medicare guidelines require frequent 
positional changes that cannot be met by a standard bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
medical history of hypertension, stroke, hyperlipidemia, dementia, hypothyroidism, and osteoporosis. A 
referral for durable medical equipment indicated that the enrollee has been having progressive weakness and 
safety issues with regards to mobility and transfers in and out of bed. The enrollee is experiencing progressive 
weakness that is impacting his mobility and ability to transfer. There is limited clinical history, specifically in 
terms of level of mobility and function, and physical examination findings. The documentation does not 
indicate that the enrollee is unable to re-position himself while in bed and requires frequent re-positioning or an 
immediate change in position, which is required for a semi-electric hospital bed versus a standard hospital bed. 
Therefore, the requested semi-electric hospital bed is not medically 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 a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 7, 2022, billed with 
codes 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
October 7, 2022, billed with codes 81314 and 81345.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve K3 foot identified with codes L5981 and L5986. 
 
You asked the Plan to pre-approve K3 foot identified with codes L5981 and L5986. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that K3 feet are only covered for certain indications. 
 
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 K3 foot identified with codes L5981 
and L5986. Our reviewer says that the documentation does not support that the requested items are medically 
reasonable or necessary. Our physician reviewer found the enrollee is noted to be fearful and can hop in place 
with contact guard assistance. This is the enrollee's initial prosthesis and the documentation does not fully 
support at this time that this enrollee will be at a K3 level. The enrollee was recommended to undergo intensive 
inpatient rehabilitation which also indicates that the enrollee also has medical conditions that require intensive 
physician supervision. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K3 foot identified with codes L5981 and L5986 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve K3 foot identified with codes L5981 and L5986.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87635 and 87640 billed for date of service 
July 15, 2022. 
 
You asked the Plan to pay for procedure codes 87635 and 87640. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 87635 is: Infectious agent detection by nucleic acid 
(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique; and of code 87640 is: Infectious agent detection by nucleic acid 
(DNA or RNA); Staphylococcus aureus, amplified probe technique. 
 
We find that CPT codes 87635 and 87640 are not supported in the medical record. Specifically, the available 
medical records do not support that testing for COVID-19 nor for Staphylococcus aureus infection was 
performed on the date of service at issue. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 87635 and 87640 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87635 and 87640 billed for date of service July 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT services. 
 
You asked the Plan to pre-approve PT services. You say that the additional PT visits are necessary. The Plan 
denied your request. The Plan says 7 additional PT visits are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the complexity of the enrollee's conditions do not require the skills of 
a professional therapist to achieve further improvement in the enrollee's symptoms or functional status. No 
medical notes from the enrollee's treating physician provides an order or need for additional skilled therapy 
services. Further utilization of the home exercise program is appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PT services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service October 31, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that there is a prior authorization on file for these 
services. The Plan denied your request. The Plan says they have agreed to pay for the other therapy services; 
however, procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service October 31, 2022.