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

 
We decided that the Plan does not have to pay for procedure codes 82570 and 83986 billed for date of service 
April 19, 2022. 
 
You asked the Plan to pay for procedure codes 82570 and 83986. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says payment for procedure codes 82570 and 83986 is 
included in the payment for procedure codes 80307 and G0481. 
 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 codes 82570 and 83986 are column II codes to column I codes 80307 and 
G0481; however, 82570 and 83986 were billed with a modifier.  
 
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 82570 and 83986. Our reviewer says that 
the procedure codes at issue do not meet criteria for payment. Our reviewer found that there are edits that exist 
between 80307 and G0481 with 82570 and 83986. The available medical documentation does not support the 
use of modifier 59 as these tests are not separate and distinct from one another. 
 
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 82570 and 83986 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 82570 and 83986 billed for date of service April 19, 
2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for health care practitioners rendering treatment in place (tip) 
(G2021) provided June 29, 2022. 
 
You asked the Plan to pay for the practitioner services. You say that you were not aware that the provider is no 
longer a part of the network and is no longer covered by the insurance. The Plan denied your request. The Plan 
says this service is not valid for Medicare purposes. 
 
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 G2021 is health care practitioners rendering treatment in 
place (tip). 
 
We find that CPT code G2021 is not supported in the medical record. Specifically, the 2022 National Physician 
Fee Schedule lists HCPCS G2021 with a status indicator of X, which indicates that this service is not valid 
for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the practitioner services have not been met. Therefore, we decided that the Plan does not have to pay for health 
care practitioners rendering treatment in place (tip) (G2021) provided June 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76706 billed for services provided on June 
16, 2022. 
 
You asked the Plan to pay for the testing services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the enrollee did not receive the study for one of the risk categories. 
 
The Plan must follow Medicare rules. Medicare rules say that the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. 
 
In this case, the CPT Code Manual definition of code 76706 is ultrasound, abdominal aorta, real time with 
image documentation, screening study for abdominal aortic aneurysm (AAA). We find that CPT code 76706 is 
not supported in the medical record. Although the diagnosis code is valid, there are insufficient medical records 
from the enrollees treating physician to show that the enrollee meets the coverage criteria for the provided 
testing. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 76706 billed for services provided on June 
16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial foot prosthesis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this was requested and was miscoded. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the partial prosthesis is not medically necessary. The device has not been shown to impact gait or 
have more impact than a well-designed shoe. The requested device is not medically necessary to meet the 
enrollee's needs. 
 
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 a partial foot prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on current needs, skilled nursing facility is more appropriate. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable with debility and does not need physician close 
supervision three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute medical issues and live alone with functional 
dependence. It is unlikely he will be making a significant functional recovery for a community discharge to live 
alone after an IRF stay. The chronicity of his skin sores will not be remedied in 12-14 days in IRF. He was 
more appropriate for a skilled nursing facility (SNF) admission and not an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on September 22, 
2021. 
 
You asked the Plan to pay for the ambulance transportation. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says the service is not paid separately when the enrollee is an 
inpatient. 
 The Plan must follow Medicare rules. Medicare rules say that when a beneficiary is an inpatient in a facility 
and requires transport elsewhere for specialized care, while maintaining inpatient status at the original provider, 
no separate Part B payment can be made for the transportation. 
 
We looked at the file and Medicare rules. The beneficiary was an inpatient at the receiving facility and had 
been sent to the origin facility for a specialized procedure. As such, this is considered patient transportation and 
is not separately payable. Payment must be sought from the facility at which the beneficiary was an inpatient at 
the time of transport. Based on this information, we decided that Medicare rules for coverage of the ambulance 
transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance 
transportation provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional power wheelchair accessories (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the upper limb strength and function are adequate for the enrollee to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 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 accessories. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has cerebral palsy with limited strength in the upper and lower extremities as well as 
reduced range of motion and coordination. He is non-ambulatory and requires a power wheelchair for mobility 
and performing his basic daily activities. He cannot perform pressure relief independently due to weakness and 
requires a power wheelchair with power tilt for adequate pressure relief. While he only requires power tilt, the 
complexity of his seating and positioning needs and the patients inability to independently operate separate 
drive controls given his lack of coordination necessitate a more complex group 3 power wheelchair base. He is 
not able to operate a simpler group 2 power wheelchair base. The expandable controller with harness and 
electronic connection are necessary to operate the group 3 power wheelchair base. Therefore, the expandable 
controller with harness and electronic connection 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 the accessories have been met. Therefore, we decided that the Plan has to pre-
approve additional power wheelchair accessories (E2311, E2313, E2377).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was necessary for the management of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says the claim 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. The claim in this case does not show that the required unique 
identifier was reported. 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 April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid 
analysis for lymphedema assessment. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the submitted records do not document treatment for lymphedema using compression, 
decongestive massage, or any other standard of care management strategies for lymphedema. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records do not document any unique features of this patient's condition which would 
necessitate the bioimpedance spectroscopy over standard clinical assessment for evaluation of this patient's 
lymphedema. A review of the recommendations in the current peer-reviewed medical literature (Up to Date) 
does not indicate that bioimpedance spectroscopy is standard of care in the detection or prevention or treatment 
of lymphedema related to breast cancer or breast cancer treatment. 
 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 bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheter insertion services provided on April 27, 2021. 
 
You asked the Plan to pay for the catheter insertion services. You say that the insurance information given to 
you was incorrect. You say that, upon receipt of corrected billing information from the enrollee, you promptly 
submitted your claim. The Plan denied your request. The Plan says the time limit for filing the claim in dispute 
has expired. 
 
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 catheter insertion services was not filed until July 15, 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 catheter insertion services provided on April 27, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services provided on August 11, 2022. 
 
You asked the Plan to pay for the transportation services. You say that the enrollee was transported from the 
emergency room of one facility to the other for surgery. The Plan denied your request. The Plan says that the 
service 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.  
 
The file shows that the enrollee received ambulance transportation from one facility to another. The records do 
show that the enrollee presented to the emergency room. However, there is not enough information in the case 
file to show that the enrollee was an inpatient of the originating facility at the time the transport occurred. 
Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided 
that the Plan has to pay for the ambulance transportation services provided on August 11, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from an IRF stay to return 
to their baseline function. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of procedure code 87500 billed for date of 
service May 18, 2022. 
 
You asked the Plan to pay for a second unit of 87500. You say that this service was billed appropriately and is 
supported in the medical record. The Plan denied your request. The Plan says a second unit of 87500 is not 
supported in the medical record, and is inappropriate as it would be highly unlikely that a second unit of 87500 
would be medically necessary for a single date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 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 a second unit of 87500 Our reviewer says 
that the Plan's denial is appropriate in this case. Our physician reviewer found the medical records do not 
support billing a second unit of 87500. In addition, Medically Unlikely Edits for this procedure code is 1. 
 
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 second unit of 87500 have not been met. Therefore, we decided that the Plan 
does not have to pay for a second unit of procedure code 87500 billed for date of service May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacral nerve stimulator for urinary incontinence.

You asked the Plan to pre-approve sacral nerve stimulator. You say that all requested procedures are needed in order to work properly. The Plan denied your request. The Plan says the records do not show why a full exposure of the for direct visualization of lead placement is necessary.

The Plan follows Medicare rules. Medicare rules state that sacral nerve stimulation for urinary incontinence is only covered under certain circumstances.

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 sacral nerve stimulator. Our reviewer says that the enrollee does not meet the Medicare criteria for a sacral nerve stimulator. Our physician reviewer found the records do not show that full open exposure of the sacrum for direct visualization of lead placement is necessary. The records show that successful percutaneous lead placement was successful during the temporary trial.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacral nerve stimulator for urinary incontinence.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740), and a core buildup (D2950) provided 
on August 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware the provider was out-
of-network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a crown (D2740), and a core buildup 
(D2950) provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intra-oral x-ray (D0150, 
D0210) provided on July 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 13, 2020 
(D0150) and March 26, 2021 (D0210). Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation and intra-oral x-ray (D0150, D0210) provided on July 27, 2022.