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

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service February 2, 
2023.  
 
You asked the Plan to pay for procedure code 84480. You say that the patient was referred for this lab work 
and it should be covered. The Plan denied your request. The Plan says payment for code 84480 is bundled into 
payment for code 84481. 
 
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 84480 
is a column II code to column I code 84481 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 84480 billed for date of service February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 6, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the Plan processed this claim incorrectly. 
The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve nine (9) month use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9-month use of a ventilator. You say that denying this authorization for a 
ventilator or downgrading to a lesser device would have devastating consequences. The enrollee needs this 
device. The Plan denied your request. The Plan says that the request for continued use of a NIV is 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. 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 9-month use of a ventilator. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has COPD 
with chronic respiratory failure and has been receiving a trilogy ventilator since 2020 with good outcomes, to 
withdraw this therapy, would not be best practice as he has had no hospitalizations since then and is compliant. 
The documentation does support the medical necessity and rationale for home ventilator. There is no role for 
step down therapy with chronic respiratory failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9-month use of a ventilator have been met. Therefore, we decided that the Plan 
has to pre-approve nine (9) month use of a ventilator (E0466).  
 
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 the stab phlebectomy. 
 
You asked the Plan to pre-approve the stab phlebectomy. You say that the enrollee has lifestyle limiting pain, 
aching, and swelling on right thigh and calf for five years. You say that the enrollee has denied benefit from six 
months of compression stocking utilization, leg elevation or use of oral analgesics. You also say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has saphenous 
reflux present and therefore this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated. 
 
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 stab phlebectomy. Our reviewer 
says that the requested stab phlebectomy is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has undergone saphenous vein reflux treatment. 
Therefore, the reviewer found that the requested stab phlebectomy 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 stab phlebectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stab phlebectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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. 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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records document 
that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) 
mode which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial 
and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
February 09, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you feel you should 
not be responsible for the billed copayment. 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 $285 
copayment for outpatient hospital services. 
 
You have been asked to pay a $285 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services 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. Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient hospital services provided on February 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve swing-away legrest calf support, joystick high 
resolution, power module 90a expandable, ankle huggers medium, upper extremity support with slides, wide 
arm pad - right and left rest and special cutout of tray (K0108x7) 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested accessories cannot be covered per Medicare rules. These 
items either already come with the wheelchair or are not needed. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Provided records document that the enrollee has 3/5 to 4/5 right upper extremity 
strength and no other documentation indicating she has inadequate right upper extremity strength and function 
to operate the wheelchair's power options with their own switches, thus criteria for the joystick are not met. 
Also, the Local Coverage Article Wheelchair Options/Accessories - Policy Article A52504 states: "K0108 
must not be used for additional features of a joystick." The items requested do not appear to serve a medical 
purpose.  Provided records do not clarify that the requested accessories are necessary for the approved 
wheelchair as K0858, E2363, E2300, E1002, E1028, E2310, E2609, E2617, E1028, E0955, E0954 have 
reportedly all been approved; the additionally requested items appear duplicative and/or medically 
unnecessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve swing-away legrest calf support, joystick high resolution, power module 90a 
expandable, ankle huggers medium, upper extremity support with slides, wide arm pad - right and left rest and 
special cutout of tray (K0108x7)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Upper Respiratory Infection Panel provided on July 11, 
2022. 
 
You asked the Plan to pay for the Upper Respiratory Infection Panel. You say that the Respiratory Panel 
provided was medically necessary. The Plan denied your request. The Plan says the Respiratory Panel provided 
was 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 pay for the Upper Respiratory Infection Panel. Our 
reviewer says that the Respiratory Panel provided was not medically necessary. Our physician reviewer found 
the extended upper and lower respiratory infection panel was not medically necessary. This enrollee had acute 
symptoms consistent with a viral respiratory infection and presented requesting a COVID test. The enrollee 
was not febrile or seriously ill. The COVID test was positive. The extended panel was not indicated because 
this enrollee did not have serious underlying disease, was not critically ill, and was not at high risk of becoming 
critically ill. 
 
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 Upper Respiratory Infection Panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the Upper Respiratory Infection Panel provided on July 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 75710. 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 75710 is bundled into 
payment for code 37224. 
 
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 75710 
is a column II code to column I code 37224. This claim has not been billed with an appropriate modifier to 
bypass the edit as the records do not support procedure code 75710 as a distinct procedural service. 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 75710 billed for date of service July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2022, billed with 
codes 81321, 81351, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the 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 
June 30, 2022, billed with codes 81321, 81351, and 81272.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 16, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair.  
 
You asked the Plan to pay for a shower chair. You say that this chair is necessary due to your worsening 
condition. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit option (K0108). 
 
You asked the Plan to pre-approve a transit option. The Plan denied your request. The Plan says the transit 
option does not primarily serve a medical purpose and would be utilized for transportation of the device out of 
the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit option (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for medical care provided on June 13, 2022,  
June 30, 2022, July 6, 2022, August 5, 2022 and September 2, 2022. 
 
You asked the Plan to reimburse you for the medical care provided on June 13, 2022, June 30, 2022,  
July 6, 2022, August 5, 2022 and September 2, 2022. You say that the services were due to a medical 
emergency. The Plan denied your request. The Plan says that the Plan is unable to make out the services provided/paid and dates of receipt. You were unable to provide any legible receipts/additional proof of 
payment.  
 
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 the Plans rules and Medicare rules. The file shows that you were unable to provide any 
legible receipts/additional proof of payment. Based on this information, we decided that Medicare rules for 
coverage of the medical care provided on June 13, 2022, June 30, 2022, July 6, 2022, August 5, 2022 and 
September 2, 2022 have not been met. Therefore, we decided that the Plan does not have to reimburse you for 
medical care provided on June 13, 2022, June 30, 2022, July 6, 2022, August 5, 2022 and September 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left stab phlebectomy of varicose veins (37765, 37766). 
 
You asked the Plan to pre-approve the stab phlebectomies. You say that the enrollee's pain interrupts her ability 
to work and walk, as they stand up all day. You say that the enrollee's pain continues despite edema wear, 
exercise, walking, elevation and Naproxen. You also say that it is unlikely that the enrollee would have 
significant relief with ablation alone. The Plan denied your request. The Plan says although the enrollee's 
tributary veins measure 10.5 millimeters in diameter and they have tried conservative treatment, saphenous 
venous incompetence (Reflux) has not been successfully eliminated. The Plan also says this is not medically 
reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated. 
 
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 stab phlebectomies. Our reviewer 
says that the requested stab phlebectomies are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has undergone saphenous vein reflux treatment. 
Therefore, the reviewer found that the requested stab phlebectomies are 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 stab phlebectomies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left stab phlebectomy of varicose veins (37765, 37766).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87641 billed for date of service January 15, 
2023.  
 
You asked the Plan to pay for procedure code 87641. You say that you have billed the service at issue 
correctly. 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 that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87641 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87641 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87641 billed for date of service January 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty and vertebroplasty (22510, 22511, 22512, 
22513, 22515). 
 
You asked the Plan to pre-approve kyphoplasty and vertebroplasty. 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 follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty and vertebroplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible causes of 
back pain. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty and vertebroplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve kyphoplasty and vertebroplasty (22510, 22511, 22512, 22513, 22515).