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

 
We decided that the Plan does not have to pay for codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 
87563, 87591, 87635, 87641, 87651, 87653, 87661, 87798, G0452 for date of service May 15, 2023. 
 
You asked the Plan to pay for codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87635, 
87641, 87651, 87653, 87661, 87798, G0452. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says providers/suppliers must not unbundle the services described by a HCPCS/CPT 
code. 
 The Plan must follow Medicare rules. Medicare rules say that a provider/supplier shall not report multiple 
HCPCS/CPT codes if a single HCPCS/CPT code exists that describes the services. This type of unbundling is 
incorrect coding. 
 
We looked at the file and Medicare rules. Review of the file shows that that the laboratory billed multiple 
individual codes with the same date of service. This is considered unbundling and these codes are not payable 
as billed. Based on this information, we decided that Medicare rules for coverage of codes 87481, 87491, 
87496, 87500, 87511, 87529, 87532, 87563, 87591, 87635, 87641, 87651, 87653, 87661, 87798, G0452 have 
not been met. Therefore, we decided that the Plan does not have to pay for codes 87481, 87491, 87496, 87500, 
87511, 87529, 87532, 87563, 87591, 87635, 87641, 87651, 87653, 87661, 87798, G0452 for date of service 
May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and one 
power seating system motor (E2310). 
 
You asked the Plan to pre-approve the electronic connection. You say that the Plan has approved the Power Tilt 
function for this enrollee, and the power functions require a total of 1 Power Actuator. You also say that when 
one power seating function/actuator/motor is provided on a power wheelchair, one unit of E2310 is allowed. 
The Plan denied your request. The Plan says that the electrical connection between the wheelchair controller 
and one motor (E2310) cannot be covered. The Plan also says that although there is one approved power 
feature on this wheelchair (power elevating leg rests), there is not a medical need to control this power feature 
through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 electronic connection. Our reviewer 
says that the requested item is considered medically reasonable and necessary in this case. Our physician 
reviewer found the complexity of the enrollees seating and positioning needs necessitates a more complex 
group 3 power wheelchair base and suspension system. The electronic connection is necessary to operate the 
group 3 power wheelchair base and the power option via a joystick. Our reviewer also found that it is required 
to operate a power option on a group 3 power 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 the electronic connection have been met. Therefore, we decided that the Plan 
has to pre-approve an electronic connection between wheelchair controller and one power seating system motor 
(E2310).  
 
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 laboratory services billed with codes 88305, 88307, 
88360, and 88342 for April 11, 2023. 
 
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 billed diagnosis is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with two diagnosis codes that cannot be billed together. Therefore, we decided that the Plan does not have to pay for the laboratory 
services billed with codes 88305, 88307, 88360, and 88342 for April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 10, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.   
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 1. You billed 2 units of this 
code, exceeding the MUE. The units in excess of the MUE were not reported on a separate claim line with an 
appropriate modifier as required. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0482) provided December 16, 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 service is 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 G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. The submitted laboratory requisition 
indicates that Urine Drug Confirmation 54 Panel was requested. The submitted documentation does not itemize 
what tests are included in this panel. 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 drug 
testing (G0482) provided December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0481) provided January 27, 2023.  
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 service is 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 G0481 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. The submitted medical records included 
a requisition form. However, the current documentation does not include an order that indicates 
specific/individual drugs being requested to support performing a definitive test of 8-14 drug classes. 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 drug testing (G0481) provided January 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have increase the reimbursement for outpatient mental health services on 
November 10, 2022, to March 01, 2023.  
 
You asked the Plan increase the reimbursement for outpatient mental health services. You say that you feel you 
were under paid. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for must pay a 20% coinsurance for each Medicare-covered individual therapy visit with a 
psychiatrist.  
 
You have been asked to pay a 20% coinsurance for outpatient mental health services. This item/service falls 
within the outpatient mental health care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. You have been reimbursed up to the approved allowed amount after the 
coinsurance was applied. Therefore, we decided that the Plan does not have increase the reimbursement for 
outpatient mental health services on November 10, 2022, to March 01, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor foot (L5973). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request for the microprocessor foot does not meet Medicare criteria for being 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that coverage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has resumed independent living and community ambulation using the existing 
prosthesis, which includes a microprocessor foot/ankle system (L5973). The existing prosthesis is ill-fitting, 
and the foot is worn-out and beyond warranty. The records sufficiently demonstrate the enrollee's K3 function, 
as well as the need for the new prosthesis generally, and the microprocessor-controlled foot specifically. The 
LCD only requires documentation of K3 level ambulation for the requested item. Microprocessor-controlled 
feet are part of the basic standard of care for all community K3 amputee ambulators given that the evidence of 
their benefits and superiority to less sophisticated alternatives are well proven and long standing.  
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a microprocessor foot (L5973).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on January 3, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says documentation of this 
service was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the services have been met. 
Specifically, the documentation submitted does not contain medical records from the non-contract provided. 
Therefore, we decided that the Plan does not have to pay for the therapy services provided on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show that you require a power scooter for use in your home. 
 
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 scooter. Our reviewer says that 
the requested power scooter is not medically necessary. Our physician reviewer found the provided 
documentation indicates you have joint pain that limits your ability to ambulate in the community. The 
documentation shows that you have normal motor strength in the majority in the upper extremities joints, 
except for the shoulder joints, which are 4/5 in strength. You are noted to be independent with transfers and 
performing daily activities in the home with the use of a walker. Therefore, the requested power scooter 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 scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that back pain. You also say that the 
enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says 
there is insufficient evidence in the published medical literature to show that this service is as safe as standard 
services and/or provides better long-term outcomes than current standard services/therapies. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet degenerative joint disease or stenosis. The reviewer found that the cause of the enrollee's pain is 
not clear. Therefore, the reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray provided on December 5, 2022. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that under the skilled nursing facility (SNF) 
Prospective Payment System (PPS) all Medicare covered Part A services that are considered within the scope 
or capability of SNFs are considered paid in the PPS rate.  
 
We looked at the file and Medicare rules. In this case, payment for the requested x-ray is included in the SNF 
payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the portable x-ray 
provided on December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 8, 2023, billed with 
codes 87481, 87491, 87563, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
May 8, 2023, billed with codes 87481, 87491, 87563, 87653, 87798, 87641, and 87500.
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 13, 
2023. 
 
You asked the Plan to pay for procedure code 20610. You say that this service should be paid as it was separate 
from the other services performed on the same date. The Plan denied your request. The Plan says the service at 
issue was not billed with the required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 27130 
provided on January 25, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services 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 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (J0896). 
 
You asked the Plan to pre-approve Reblozyl. You say that the patient is under your care for myelodysplastic 
syndrome with ringed sideroblasts, is transfusion dependent and has failed Procrit prior. You also say that you 
are requesting Reblozyl to reduce transfusional support and future iron overload. The Plan denied your request. 
The Plan says the requested use of the medication is not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 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 Reblozyl. Our reviewer says that 
Reblozyl is not medially reasonable and necessary. Our physician reviewer found the FDA has not stated that 
the requested drug is indicated for the patient's condition. The Medicare approved cancer drug compendia do 
not contain a supportive citation for the use of the requested drug in the patient's clinical situation. Our 
reviewer found no literature from the Medicare approved cancer journals were submitted for review. The 
elements of the coverage criteria are not satisfied. Our physician reviewer also found that the requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl (J0896).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the freestanding emergency room (ER) services rendered on 
May 21, 2023. 
 
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 provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
freestanding emergency room (ER) services rendered on May 21, 2023.