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

 
We decided that the Plan does not have to pay for lab services billed with code 81345 provided on March 31, 
2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 billed with code 81345 provided on March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 for date of service March 17, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, the laboratory results 
provided within the medical records does not support the testing of five fungi pathogens. The results indicated 
that only Candida lusitaniae, Candida dubliniensis, and Candida albicans were tested on the billed service date. 
The results did not show that additional fungi pathogens were tested. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87481 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87481 for date of service March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87641, 87801, 87500, 87798, 87651, and 
87640 for date of service April 13, 2023. 
 
You asked the Plan to pay for procedure codes 87641, 87801, 87500, 87798, 87651, and 87640. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87641, 87801, 87500, 87798, 87651, and 87640 are not payable as billed. Specifically, 
the documentation shows that the services provided was a panel. A panel cannot be unbundled and billed as 
individual components. These codes are not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87641, 87801, 87500, 87798, 87651, and 87640 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87641, 87801, 87500, 
87798, 87651, and 87640 for date of service April 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a L3 kyphoplasty. 
 
You asked the Plan to pre-approve the L3 kyphoplasty. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the magnetic resonance imaging (MRI) findings 
corroborate additional pathology that could be contributing to the enrollee's back pain. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary when an acute or subacute osteoporotic vertebral compression fracture is present. 
 
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 L3 kyphoplasty. Our reviewer says 
that the requested L3 kyphoplasty is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate a diagnosis and/or treatment for osteoporosis. The reviewer found that there is 
no documentation of a progression of the body height loss, greater than 25% vertebral body height loss, 
kyphotic deformity, or a severe impact on daily activities. The reviewer also found that the MRI did not 
corroborate a vertebral compression fracture at L3. Therefore, the reviewer found that the requested L3 
kyphoplasty is not medically reasonable or 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 L3 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a L3 kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for in-home remote sleep study monitoring provided on March 
08, 2023. 
 
You asked the Plan to pay for in-home remote sleep study monitoring. You say that this was medically 
necessary and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for in-home remote sleep 
study monitoring provided on March 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump (E0455). 
 
You asked the Plan to pre-approve an external pump. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says an external pump for the infusion of 
vancomycin is not covered. The Plan also says that the record does not show that you need Zosyn continuously 
through a vein for at least eight hours. 
 
The Plan follows Medicare rules. Medicare rules say that the coverage of vancomycin as a durable medical 
equipment infusion pump benefit is not covered. The rules also say that an external infusion pump is covered 
for the administration of other drugs when the criteria listed in the Medicare rules section are 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 an external infusion pump. Our 
reviewer says that the external pump is not medically necessary. Our physician reviewer found that a 
continuous infusion pump is not necessary, and the antibiotic treatment can be delivered through bolus 
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 an external infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external infusion pump (E0455).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation states failure of 
BIPAP and transition to average volume assured pressure support (AVAPS) but no arterial blood gas (ABG) 
results to confirm this.  The enrollee appears to have benefited from BIPAP and AVAPS addition. There is no 
clear data to suggest that the enrollee requires a home ventilator at this junction.  The enrollee is a good 
candidate, evident in documentation, for BIPAP with or without AVAPS. The enrollee was having an acute 
COPD exacerbation and hence required more support. Therefore, based on documentation provided and data 
points, the enrollee does not meet best practice at this time to require a home ventilator and AVAPS can be 
delivered with BIPAP for the setting requested. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility stay provided on August 30, 2022. 
 
You asked the Plan to pay for the nursing facility stay. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nursing facility stay 
provided on August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a right total 
shoulder arthroplasty surgery.  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee is undergoing a 
planned right total shoulder arthroplasty and tenodesis of the long tendon of the biceps. He is medically stable 
and has been provided medical clearance to undergo this elective procedure. The planned procedure is listed 
under current procedure terminology (CPT) code 23472 and is not listed on the Centers for Medicare and 
Medicaid Services (CMS) Inpatient Only List. The procedure is currently approved as an ambulatory 
procedure. A review of the records reveals there is no history of cardiac, pulmonary, or renal disease. The is no 
history of previous surgical or anesthesiology complications. The enrollee is hemodynamically and medically 
stable. There is no documentation provided to support the expectation that the enrollee will require a greater 
than two midnight stay for this 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an acute inpatient hospital admission for a right total shoulder arthroplasty surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7310 
x2). 
 
You asked the Plan to pre-approve the dental services. You say that you have been getting dental abscesses/ 
infections which have already had to be treated in the emergency room while waiting for surgery. 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 Plan's 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 alveoloplasty in conjunction with extractions (D7310 x2) was exhausted on October 3, 
2023 when the Plan authorized the surgical removal of residual tooth roots (D7250 x2). Therefore, we decided 
that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7310 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided 
September 22, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. The definition of code G0483 
is dug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service. 
 
Code G0483 is not supported because the submitted medical records do not include order requisition of 
definitive drug test(s), 22 or more drug classes per date of service. Code 80307 is not supported because the 
submitted medical records do not include order for drug test(s), presumptive, any number of drug classes, any 
number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry 
either with or without chromatography, includes sample validation when performed, per date of service. Based 
on this information, we decided that Medicare rules for coverage of the drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (80307 and G0483) 
provided September 22, 2022.
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 the enrollee remains medically ready and a bed is 
available. The Plan denied your request. The Plan says the records indicate the enrollee may not be able to 
tolerate an intensive schedule consisting of 3 hours of daily therapies and does not have complex rehabilitation 
needs that require frequent evaluation by a rehab doctor.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device (22612). 
 
You asked the Plan to pre-approve a Minuteman G3R Interspinous device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Minuteman G3R Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the minuteman device 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 a Minuteman G3R Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device (22612).
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 the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternate setting.  
 
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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940, 98942), 
manual therapy (97140), mechanical traction therapy (97012), supplies and materials (99070), preventive 
medicine counseling and/or risk factor reduction intervention (99401), and the extraspinal chiropractic 
manipulative treatments (98943) provided from February 11, 2021, through November 19, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as the claim 
was submitted untimely.  
 
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 these services was not filed until January 27, 2023. This means that more 
than one calendar year from the dates of service had passed before a claim was filed.  
  
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940, 
98942), manual therapy (97140), mechanical traction therapy (97012), supplies and materials (99070), 
preventive medicine counseling and/or risk factor reduction intervention (99401), and the extraspinal 
chiropractic manipulative treatments (98943) provided from February 11, 2021, through November 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 rendered on November 17, 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 denied code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93229 is "External mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional." 
 We find that CPT code 93229 is not supported in the medical record. Specifically, billed date of service does 
not match the date of service in the records. 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 
procedure code 93229 rendered on November 17, 2022.