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

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code 99204. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is: Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter. 
 We find that CPT code 99204 is not supported. Specifically, the Plan has documented that the enrollee is not a 
new patient to the practice. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99204 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99204 billed for date of service November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

  
We decided that the Plan does not have to pay for  the multiplex PCR panel coded as 87481, 87491, 87500, 
87529, 87556, 87591, 87641, 87661, 87798 provided April 12, 2022. 
 
You asked the Plan to pay for  the laboratory service. You say that due to the critical clinical value of the 
testing that benefits the enrollee, you ask for reconsideration of the denial ad request payment in full for the 
testing. The Plan denied your request. The Plan says there is lack of support for the clinical utility of large 
multiplex PCR urinary tract infection panel tests. There is a lack of data to suggest these panels alter medical 
decision making. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
We looked at the file and Medicare rules. 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  the multiplex PCR panel coded as 87481, 87491, 87500, 87529, 87556, 87591, 87641, 87661, 87798 
provided April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 5, 2022, to 
April 7, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code E43, described as 
unspecified severe protein calorie malnutrition. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not 
support the billed code. Our physician reviewer found that the enrollee was treated for elevated 
ammonia/hepatic encephalopathy. While the enrollee is noted to have had a recent weight loss, this appears to 
be attributable to a large volume paracentesis performed five days prior to the hospitalization. The enrollees 
serum albumin level was normal. Severe malnutrition does not appear to have affected the course of 
treatment/hospitalization. As such, the billing of E43 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 5, 2022, to April 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve a power wheelchair. You say that a power wheelchair is needed due to her 
illness. The Plan denied your request. The Plan says that the requested power wheelchair is not medically 
necessary. 
 
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 coverage criteria has not been met. Our physician reviewer found that the record indicates you can self-
propel your manual wheelchair. 
 
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 Group 2 power wheelchair (K0823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure, probable asthma and less likely to be chronic obstructive pulmonary disease (COPD). He 
also has diagnoses of atelectasis, tracheobronchomalacea, obstructive sleep apnea (OSA), heart failure, 
pulmonary hypertension and obesity hypoventilation syndrome. The ventilator is being requested for use in a 
pressure support mode with safety tidal volume and expiratory positive airway pressure (EPAP), which could 
be provided by a BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. 
Medicare does not cover a ventilator for this purpose. 
 
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 pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say the enrollee meets all applicable Medicare criteria for 
admission to the IRF, and you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
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 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 87631 for date of service May 
2, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 87631 
for date of service May 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minuteman procedure (20930). 
 
You asked the Plan to pre-approve the minuteman procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the minuteman procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of 
large-volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
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 the minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the minuteman procedure (20930).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the dialysis services provided from January 2, 2022, to January 29, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services should be reimbursed per the fee 
schedule.  The Plan denied your request. The Plan says that there was invalid billing on the claim.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The case file shows that the claim denied due to the invalid billing of code J0604. The Plan has not provided 
Medicare rules to substantiate their denial. The Local Coverage Article, A55992, in the case file does not have 
jurisdiction where the services were provided. The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request.  Therefore, we decided that the 
Plan has to pay for the dialysis services provided from January 2, 2022, to January 29, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve patent foramen ovale (PFO) placement. 
 
You asked the Plan to pre-approve PFO placement. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has 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 PFO placement. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found clinical studies have shown significantly higher per-procedural complications in older age 
groups; hence guidelines do not recommend PFO closure in patients over age 60. As such, guidelines would 
not support the need for a PFO closure device. In summary, there is insufficient documentation to support the 
medical necessity for the requested PFO closure in this enrollee's clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PFO placement have not been met. Therefore, we decided that the Plan does not 
have to pre-approve patent foramen ovale (PFO) placement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that insertion, subcutaneous cardiac rhythm monitor, 
including programming is considered reasonable and necessary when syncope (passing out) is thought to be 
cardiac-related, but is too infrequent to be detected by an external heart monitor.  
 
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 ILR. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for this device. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the implantable loop recorder (ILR) (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart procedure. 
 
You asked the Plan to pre-approve Optimizer Smart. You say that the physician has decided to opt for 
Optimizer because otherwise there are no available treatment options. The Plan denied your request. The Plan 
says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Optimizer Smart. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this procedure remains the subject of multiple studies examining long-term efficacy 
as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such studies are 
completed, it is premature to presume clinical outcomes and benefits.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Optimizer Smart procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 testing billed for date of service August 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says that the procedure code is not on the list of codes on the DEX registry.  
 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 looked at the file and the rules. A review of the claim does show that the required unique identifier was 
reported. We also find that the test was accurately billed with code 81479, per billing guidelines in the Local 
Coverage Article, A58192. Based on this information, we decided that Medicare rules for coverage of the 
billed services have been met. Therefore, we decided that the Plan has to pay for the Guardant360 testing billed 
for date of service August 10, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine provided on January 18, 2023. 
 
You asked the Plan to pay for Bupivacaine. You say that the drug at issue has been billed correctly. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the drug at issue is included in the global surgery 
payment for the procedure coded 20610 provided on the same date. Based on this information, we decided that 
Medicare rules for coverage of the drug at issue have not been met. Therefore, we decided that the Plan does 
not have to pay for Bupivacaine provided on January 18, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for evaluative and therapeutic otorhinolaryngologic services provided on 
January 10, 2023. 
 
You asked the Plan to pay for evaluative and therapeutic otorhinolaryngologic services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says that a covered diagnosis has not 
been billed for evaluative and therapeutic otorhinolaryngologic services. 
 
The Plan must follow Medicare rules. Medicare rules say that certain diagnosis codes support medical 
necessity of the evaluative and therapeutic otorhinolaryngologic services.  
 
We looked at the file and Medicare rules. Review of the file shows that the Plan states that the diagnosis codes 
billed do not fall under the coding and billing requirements. While the LCA does have a list of diagnosis codes 
that support medical necessity, the LCA does not state that any code not listed is not covered. This means the 
Plan did not substantiate their denial. Based on this information, we decided that Medicare rules for coverage 
of evaluative and therapeutic otorhinolaryngologic services have not been met. Therefore, we decided that the 
Plan has to pay for evaluative and therapeutic otorhinolaryngologic services provided on January 10, 2023.  
 
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.