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

 
We decided that the Plan does not have to pay for neuroplasty (procedure code 64712) provided to the enrollee 
on March 14, 2022. 
 
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 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 CPT code. 
 
In this case, the CPT Code Manual definition of code  is "Neuroplasty, major peripheral nerve, arm or leg, 
open; sciatic nerve." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that there is insufficient 
documentation to support modifier -59 as a distinct and separate procedure from the primary procedure performed. The documentation does not meet the required criteria for modifier -59. 
 
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 neuroplasty (procedure code 64712) provided to the enrollee on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs while you live in the SNF. 
 
You asked the Plan to pre-approve the DME. You say that the repairs are necessary. The Plan denied your 
request. The Plan says Medicare only covers DME for use in the home and does not consider a SNF a home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the DME is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve wheelchair repairs while you live in the SNF.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (CPT code(s): 
22515, 22514). 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not 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 the services. Our physician reviewer 
found the imaging studies show the L1 fracture has bone retropulsion into the spinal canal which is a relative 
contraindication to kyphoplasty 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (CPT code(s): 22515, 22514).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(CPT code 78452). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is in need of nuclear stress test. The 
Plan denied your request. The Plan says the enrollee's records do not show their current symptoms, doctors 
finding and previous test results suggestive of unstable blood flow to the heart or high risk for coronary artery 
disease. The Plan states neither do they show the enrollee is undergoing a high-risk surgery. 
 
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 service. Our physician reviewer 
found the enrollee has no cardiac symptoms. There is no specific indication for the requested study. The review 
has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (CPT code 78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronary angiogram (93454) provided to the enrollee on 
September 6, 2022. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that the enrollee did not meet criteria for approval of these services. 
 
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 these services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Percutaneous 
transluminal angioplasty (PTCA) of the chronic total occlusion (CTO) was unsuccessful, and medical therapy 
was advised. Documentation does not support the rationale for performing PTCA of the CTO given the clinical 
history provided. Guidelines do not support a need for performance of this intervention in this setting. Our 
physician reviewer found that the enrollee's condition did 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 pay for the coronary angiogram (93454) provided to the enrollee on September 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport (A0431) provided December 25, 
2021. 
 
You asked the Plan to pay for the air ambulance transport. You say that the transport was medically necessary. 
The Plan denied your request. The Plan says treatment for these conditions could be provided at the original 
hospital. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 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 air ambulance transport. Our reviewer 
says that the air ambulance service was not medically reasonable and necessary. Our physician reviewer found 
that the documentation does not support that the enrollees condition was such that the time needed to transport 
by ground, or the instability of transportation by ground, posed a threat to the enrollees survival or seriously 
endangered the enrollee's health. Transportation time by ground would be less than one hour and there is no 
documentation that this time would have risked safety of the enrollees care if transportation from the initial 
facility was necessary. The documentation does not support that the transferring hospital did not have adequate 
facilities to provide the medical services needed by the enrollee. The transferring facility had the capacity to 
provide the needed intensive care 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 the air ambulance transport have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance transport (A0431) provided December 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes. 
Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous 
glucose monitor (CGM).
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 this is medically necessary. The Plan denied your 
request. The Plan says all of the requirements for admission have not been met. 
 
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 you do not have documented skilled nursing or skilled therapy needs. You are 
functioning at a level commensurate with your injury and weight-bearing restriction. Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, 
which are custodial and intermittent, can as a practical matter be provided at a lower level of care, such as 
home, assisted living, or long-term care. 
 
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: Favorable

 
We decided that the Plan has to pay for the FoundationOneCDx (F1CDx) genetic testing (0037U) provided on 
March 7, 2022. 
 
You asked the Plan to pay for the F1CDx genetic testing. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case of a molecular pathology test 
performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT, the date 
of service must be the date the test was performed if the criteria in the Medicare Rules section of this letter are 
met. 
 
In this case the laboratory test performed is considered an ADLT. The sample in this case was collected during 
a hospital outpatient encounter. Therefore, the date-of-service was correctly reported as the date the test was 
performed, March 7, 2022. Therefore, we decided that the Plan has to pay for the FoundationOneCDx (F1CDx) 
genetic testing (0037U) provided on March 7, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are unable to walk without assistance. The 
Plan denied your request. The Plan says you do not require skilled services on a daily inpatient basis. 
 
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 services. Our physician reviewer 
found that you were admitted to the hospital after a mechanical fall resulted in a vertebral compression fracture. 
The most recent therapy documentation indicates you are able to ambulate up to 150 feet with a walker without 
hands on assistance. You can accomplish all mobility without hands on assistance but do need help putting the 
brace on. You are medically stable and without any acute exacerbations of chronic medical problems. Your 
physical function is at or near your baseline. Therefore, an admission to a SNF for inpatient skilled rehab 
services 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement services provided on April 
19, 2022. 
 
You asked the Plan to waive the copayment for the debridement services. You say that this should not be billed 
as an outpatient surgery. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $245 
copayment for surgery at an outpatient hospital.  
 
You have been asked to pay the allowed amount of $155.26, which is less than the $245 copayment for the 
debridement services. The debridement services fall within the Outpatient Hospital Services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the debridement services provided on April 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nasal endoscopy and laryngoscopy provided to the enrollee 
on November 2, 2020. 
 
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 records do not support the services 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 the denied codes is: 
 
CPT 31231: 
 
Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 
 
CPT 31575: 
 
Laryngoscopy, flexible; diagnostic 
 
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 services at issue in this case were not supported by the medical records. Our reviewer found that the procedure report does not 
include documentation of a diagnostic nasal endoscopy or a diagnostic laryngoscopy, flexible. The denied 
codes 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 nasal endoscopy and laryngoscopy provided to the enrollee on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided April 1, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you are the sole provider of this 
service, therefore the enrollee did not have an in-network option. The Plan denied your request. The Plan says 
the billing of modifier KH and KX is not eligible for payment. 
 
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 K0606 KX and K0606 KH is Automatic external 
defibrillator, with integrated electrocardiogram analysis, garment type  
 
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 automatic external defibrillator. Our reviewer says that 
the criteria has not been met for Medicare Level of coverage. Our reviewer found the provider reported Healthcare Common Procedure Coding System (HCPCS) K0606 Wearable, automatic, external defibrillators 
with integrated electrocardiogram analysis with modifiers KH: DMEPOS item, initial claim, purchase or first 
month rental, and KX: a signal on a claim that through the patient services have met the capped amount 
allowed, the provider deems continues care medically necessary.  Documentation submitted was reviewed and 
does not meet criteria. Per CMS "Devices coded K0606 and E0617 are classified by the Food and Drug 
Administration as Class III devices; therefore, all claims for code K0606 and E0617 must include the KF 
modifier. Claim lines billed without a KF modifier will be rejected as missing information".  In this case 
documentation shows provider reported K0606 with modifiers RR, KH and KX therefore services were billed 
with missing modifier. 
 
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 automatic external defibrillator have not been met. Therefore, we decided 
that the Plan does not have to pay for the automatic external defibrillator, with integrated electrocardiogram 
analysis, garment type (K0606) provided April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity angiogram to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON lower extremity angiogram. You say that the requested procedure 
was ordered when the provider was still in network. You say that the codes for surgery were already approved 
at 100%. The Plan denied your request. The Plan says there are network providers who are able to supply the 
services needed. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a lower extremity angiogram to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide. 
 
You asked the Plan to pay for a stair glide. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 pay for a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig (E1399) purchased April 1, 2022. 
 
You asked the Plan to pay for the wig. You say that you are appealing the Plan's decision to not cover the cost 
of $189.32 for the wig prescribed by your doctor. The Plan denied your request. The Plan says wigs are not 
primarily medical in nature and is not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
 
 In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig (E1399) 
purchased April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an alveoplasty and bone debridement provided on  
April 11, 2022. 
 
You asked the Plan to pay for an alveoplasty and bone debridement. The Plan denied your request. The Plan 
says these services were performed during extraction of 13 teeth. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an alveoplasty and bone debridement have not been met. Therefore, we decided that the Plan does 
not have to pay for an alveoplasty and bone debridement provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on March 9, 
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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until March 21, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for radiology services provided to the enrollee on March 9, 2021.