Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit (G0402, G0463) provided on June 16, 
2022. 
 
You asked the Plan to pay for the outpatient visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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. 
 
We find that CPT code G0402, & G0463 is not supported in the medical record. Specifically, multiple visits on 
the same day were reported without condition code G0 reported. Based on this information, we decided that 
Medicare rules for coverage of the outpatient visit have not been met. Therefore, we decided that the Plan does 
not have to pay for an outpatient visit (G0402, G0463) provided on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided July 20, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim to be 
reconsidered for payment for medical necessity, as pneumatic compression devices are a proven treatment for 
deep venous thrombosis. The Plan denied your request. The Plan says pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say 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 a pneumatic compression device (E0676) provided July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lipid panel (80061), hemoglobin (84443), and thyroid 
stimulating hormone (83036) testing provided on September 23, 2022. 
 
You asked the Plan to pay for the lipid panel, hemoglobin and thyroid stimulating hormone testing. You say 
that these tests were medically necessary. The Plan denied your request. The Plan says screening tests are not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.  
The test at issue in this appeal, the lipid panel, hemoglobin and thyroid stimulating hormone testing, was 
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the lipid panel (80061), hemoglobin (84443), and 
thyroid stimulating hormone (83036) testing provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2083 billed for date of service September 
9, 2022. 
 
You asked the Plan to pay for procedure code G2083. You say that the enrollee needed this service. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G2083 is 1. The MAI value for this code is 2. You billed 84 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G2083 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G2083 billed for date of service September 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on August 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 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 dermatology services provided on August 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic bathtub (E1399). 
 
You asked the Plan to pre-approve a therapeutic bathtub. You say that you have done research that this bathtub 
will help with your hereditary motor and sensory neuropathy. The Plan denied your request. The Plan says the 
requested bathtub is not a covered benefit with your Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that a therapeutic bathtub is not covered 
because they are not primarily medical in nature.  
 
While a therapeutic bathtub may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a therapeutic bathtub (E1399).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that continued inpatient skilled nursing facility care is 
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 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 that based on the medical records provided, there is no documentation that indicates 
further daily skilled services are required. Although the records document that you are still very limited 
functionally, the records do not document a significant improvement in your functional status despite one 
month of daily therapy treatment. Further improvement in your functional status does not appear to be 
predictable in a reasonable time frame to necessitate further daily skilled therapy services; transition to part 
time therapy services now appears to be appropriate. Additionally, as a practical matter, you do not require the 
services on an inpatient basis, only in a skilled nursing facility setting. The records support that services in a 
long-term care facility on a part time basis are now appropriate in this case. 
 
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 continued inpatient skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methocarbamol. 
 
You asked the Plan to pre-approve Methocarbamol. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 pre-approve Methocarbamol.  
 
Benefits for Methocarbamol 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a licensed 
professional counselor from July 8, 2022, to August 29, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that services have been approved 
in the past and these claims should be paid. The Plan denied your request. The Plan says the provider of service 
is ineligible to bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  The services in dispute 
in this case were provided by a Licensed Professional Counselor, which is not a Medicare-approved provider 
type to bill for outpatient mental health services.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does 
not have to pay for outpatient mental health services provided by a licensed professional counselor from July 8, 
2022, to August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing (0239U) provided on 
May 1, 2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the FoundationOne Liquid CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne Liquid CDx testing (0239U) provided on May 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing (0239U) provided on 
April 12, 2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the FoundationOne 
Liquid CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne Liquid CDx testing (0239U) provided on April 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home supply of methadone billed with code G2078 
for October 3, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2078 was not billed by a provider enrolled 
as an OTP. Therefore, we decided that the Plan does not have to pay for the take home supply of methadone 
billed with code G2078 for October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99152) provided on August 2, 2022. 
 
You asked the Plan to pay for the sedation services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is 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 CPT code. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, this service is included in 
code 45385 billed on the same date of service. Based on this information, we decided that Medicare rules for 
coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay 
for sedation services (99152) provided on August 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service November 7, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this claim denied as a duplicate in error. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basivertebral nerve ablation (64628). 
 
You asked the Plan to pre-approve a basivertebral nerve ablation. The Plan denied your request. The Plan says 
there is insufficient data to show that this treatment improved health outcomes and is therefore considered to be 
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 a basivertebral nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/investigational procedure. 
 
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 basivertebral nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a basivertebral nerve ablation (64628).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a powered operated vehicle (power scooter) with bigger tires 
(K0812). 
 
You asked the Plan to pre-approve a power scooter with bigger tires. You say that the larger wheel on an 
electric scooter will help you move around easier because you are tall, and height will be an issue for leg room. 
The Plan denied your request. The Plan says that the power scooter with bigger tires is not the most appropriate 
mobility device for you at this time. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 scooter with bigger tires. Our 
reviewer says that you need this medical item. Our physician reviewer found that you have limited mobility 
and cannot functionally use a cane or walker for mobility. You have limited upper extremity strength and range 
of motion and cannot propel a manual wheelchair. You require a power scooter for mobility and performing 
daily activities. Your home has been evaluated for accessibility. You currently have a standard 3-wheel group 1 
power scooter that is 6 years in age but given your size and necessity to operate the power scooter on even 
terrain you require a group 2 power scooter with 4 wheels for enhanced safety so that the scooter does not tip 
over. Therefore, the group 2 power scooter with 4 wheels is 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 power scooter with bigger tires have been met. Therefore, we decided that the 
Plan has to pre-approve a powered operated vehicle (power scooter) with bigger tires (K0812).  
 
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.