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

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on October 4, 
2021, to October 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that when checking the member's 
benefits, there is no indication of any kind that the Plan requires prior authorizations for care. The Plan denied 
your request. The Plan says the rendering provider is a non-participating provider and there is no referring 
provider involved in these services. The Plan also says that they did not authorize any services for this 
provider. 
 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 chiropractic manipulative treatment provided on 
October 4, 2021, to October 6, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mastectomy bra and prosthesis rendered on September 
17, 2021. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 mastectomy bra and prosthesis rendered on September 17, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opioid treatment program and a take-home supply of 
methadone provided from March 6, 2022, to May 15, 2022. 
 
You asked the Plan to pay for Opioid treatment program and a take-home supply of methadone. You say that 
the Opioid treatment program and a take-home supply of methadone were medically necessary. The Plan 
denied your request. The Plan says this provider type is not eligible to in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and the Medicare rules. The provider at issue in this case is a Substance Abuse Facility 
Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program.. Therefore, we decided that the Plan does not have to pay for Opioid treatment program and a take-home supply 
of methadone provided from March 6, 2022, to May 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes 
(81455) provided May 19, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this letter and the attached documents 
support the medical necessity of the tests requested. The Plan denied your request. The Plan says service does 
not meet Medicare NCD/LCD criteria. 
 
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 find that CPT code 81455 is not supported in the medical record. Specifically, the claim was 
billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was 
collected on May 6, 2022 rather than the billed date of service May 19, 2022. There is no documentation to 
support genetic testing on the billed date of service. The date of service for a clinical laboratory test or the 
technical component of physician pathology service must be the date the specimen was collected. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater 
genes (81455) provided May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that this was a coronavirus office visit. You say 
that coronavirus related services are exempt from in or out of network participation. You also say that this does 
not require authorization. The Plan denied your request. The Plan says prior 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 the office visit (99202) provided on February 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings that were issued on May 12, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you need to get your lymphedema under 
control so you can move more freely. The Plan denied your request. The Plan says this is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings are noncovered because they 
do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings that were issued on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve a Vacuum Assisted Socket System (VASS). You say that the vacuum socket 
system is medically necessary. The Plan denied your request. The Plan says the use of vacuum pumps for 
residual limb volume management and moisture evacuation systems among amputees is unproven and not 
medically necessary due to insufficient evidence of safety and/or efficacy. 
 
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 Vacuum Assisted Socket System 
(VASS). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found according to Medicare, additional features or components 
to a prosthesis may be necessary depending on the beneficiarys potential functional abilities. Potential 
functional ability is based on the reasonable expectations of the prosthetist, and treating practitioner, 
considering multiple factors. These factors include the beneficiarys past history, current condition including 
the status of the residual limb and the nature of the other medical problems and the beneficiarys desire to 
ambulate. In this case, the requested device has not been shown to be superior to other standard treatments for 
the medical condition. 
 
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 Vacuum Assisted Socket System (VASS) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual 
limb volume management and moisture evacuation system (L5781).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 1 standard, portable, 
sling/solid seat and back, patient weight capacity up to and including 300 pounds (K0813). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the wheelchair is necessary. The Plan 
denied your request. The Plan says the requested wheelchair does not meet coverage criteria for approval. The 
medical information received indicates that the enrollee has the muscle strength to propel himself in a manual 
wheelchair and, therefore, this does not comply with the Medicare LCD. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not 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 wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found according to Medicare a power 
mobility device is medically necessary if a beneficiary has a mobility limitation that significantly impairs his 
ability to participate in one or more mobility-related activities of daily living. The mobility limitation cannot be 
sufficiently and safely resolved by the use of a fitted cane or walker, or the beneficiary does not have sufficient 
upper extremity function to self-propel an optimally configured manual wheelchair.  Additionally, if any POV 
or PWC is only for use outside the home, it is denied as noncovered. The enrollee must also have the mental 
and physical capabilities to safely operate the power wheelchair and the home provides adequate access 
between rooms, maneuvering space, and surfaces for the operation of the PWC. The documentation does not 
support that the enrollee could not propel himself in a manual wheelchair, therefore the requested PWC 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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair, group 1 standard, portable, sling/solid seat and back, patient 
weight capacity up to and including 300 pounds (K0813).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that the claim was denied in error. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The  claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 lab services provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63030, 63035-LT, and 63035-59-RT billed 
for date of service May 26, 2022. 
 
You asked the Plan to pay for procedure codes 63030, 63035-LT, and 63035-59-RT. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment for 
code 63030 is bundled into payment for code 63267. The Plan says that code 63035 is an add-on code to code 
63030, and as code 63030 is not payable, then the add-on code 63035 is not 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. In this case, we have confirmed that code 63030 
is a column II code to column I code 63267. This claim has not been billed with an appropriate modifier to 
bypass the edit. We have also confirmed that code 63035 is an add-on code and has not been billed with an 
appropriate primary procedure code, as code 63030 is also not payable in this case. 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 codes 63030, 63035-LT, and 63035-59-RT billed for date of service May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82947 billed for date of service January 8, 
2021. 
 
You asked the Plan to pay for procedure code 82947. You say that this service is supported and should be paid. 
The Plan denied your request. The Plan says this code is 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. In this case, the CPT Code Manual definition of 
code 82947 is glucose; quantitative, blood (except reagent strip). 
 
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 code 82947. Our reviewer says that the reported 
procedure cannot be found in the laboratory report. Our reviewer found the medical record does not include 
documentation of quantitative, blood glucose testing.  
 
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 code 82947 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 82947 billed for date of service January 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 20610. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 20610 is bundled into payment for code 27096. 
 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 20610 
is a column II code to column I code 27096. 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 20610 billed for date of service April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 5, 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 the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 laboratory services 
rendered on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphometric analysis (CPT code 88360) provided on 
January 20, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not covered as billed. 
 
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 the service have not been met. The billed procedure codes 88360, 
has a physician Fee Schedule PCTC indicator of 1 and the claim a POS of 21- Inpatient hospital. As per 
review, the provider is an independent laboratory (81), but the claim was billed with place of service "21" and 
the claim was billed incorrectly without modifier "26". The Medicare rule for payment of this claim has not 
been met as the professional interpretation of a diagnostic test must be separately billed with modifier-26 by the 
interpreting physician. Therefore, we decided that the Plan does not have to pay for the morphometric analysis 
(CPT code 88360) provided on January 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; 
therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT code 97110-GP-
CQ-KX) provided on August 20, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says they have insufficient documentation to corroborate the services so they cannot confirm 
Medicare coverage has 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 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 found the documentation does not 
support that the code was appropriate for the services billed. 
 
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 therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT code 97110-GP-CQ-KX) provided on August 20, 
2021.