Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 skilled nursing visits and 8 home health aide visits.  
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 skilled nursing visits and 8 home health aide visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs) at two spinal levels.  
 
You asked the Plan to pre-approve the two-level ESI. You say that the requested services should be approved.  
The Plan denied your request. The Plan says there is no need for more than one ESI in this spinal region at this 
time.  
 
The Plan follows Medicare rules. Medicare rules say that most conditions would not require more than one ESI 
per spinal region.  
 
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 two-level ESI. Our reviewer says 
that the requested second level of ESI treatment is not shown to be reasonable and necessary. Our physician 
reviewer found while treatment with ESI is appropriate in this situation, the Plan has approved this at one level. 
There is no specific documentation supporting the necessity of ESI at a second level. 
 
 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 two-level ESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve epidural steroid injections (ESIs) at two spinal levels.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathogen testing provided on June 1, 2022, billed with 
code 87491. 
 
You asked the Plan to pay for the lab testing as billed. You say that this was billed correctly according to 
Medicare rules and must be paid.  The Plan denied your request. The Plan says all codes were approved except 
for 87491 as this test is not documented.  
 
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 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. 
 
We find that CPT code 87491 is not supported in the medical record. Specifically, the lab report does not 
include results for the pathogen chlamydia trachomatis. Based on this information, we decided that Medicare 
rules for coverage of the lab testing as billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the pathogen testing provided on June 1, 2022, billed with code 87491.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 87505 for December 
28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with 
code 87505 for December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87631) provided on March 9, 2023. You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. 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 laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87631) 
provided on March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an SD card. 
 
You asked the Plan to pre-approve an SD card. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an SD card.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 87798 
billed for date of service November 1, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653 and 87798. You say that you have 
billed the services at issue correctly. The Plan denied your request. The Plan says payment for procedure code 
87150 is included in payment for procedure code 87500, and payment for procedure codes 87481, 87641, 
87653 and 87798 is included in payment for procedure code 87801. 
 
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 87150 us a column II code to column I code 87500 and that codes 
87150, 87481, 87641, 87653 and 87798 are column II codes to column I code 87801. 
 
Codes 87481 and 87653 have not been billed with an appropriate modifier to bypass the edit. However, codes 
87150, 87641 and 87798 were billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87150, 87641 and 87798. Our reviewer says 
that procedure codes 87150, 87641 and 87798 do not meet criteria for payment. Our reviewer found that based 
on the medical records provided, the tests were performed on the same urine specimen at the same time and 
records do not support that the services at issue were distinct and separate as defined by Medicare criteria. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87641, 87653 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 
87798 billed for date of service November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service January 10, 
2023. 
 
You asked the Plan to pay for procedure code 87150. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -XU modifier is not supported as a separate and 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 87150 billed for date of service January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit/tie down (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested accessory does not serve a primary medical purpose and 
would be used outside of the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a transit kit/tie down (K0108).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eleven (11) home health physical therapy (PT) visits 
(G0151). 
 
You asked the Plan to pre-approve home health services. You say that the additional PT visits are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the records do 
not show that skilled therapy services are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration beyond what was approved by the health plan. The 
enrollee has had prior PT and her functional level and prior instruction on a home exercise program do not 
support the need for ongoing skilled PT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eleven (11) home health physical therapy (PT) visits (G0151).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total of 99 additional home health skilled nursing 
visits over two months.  
 
You asked the Plan to pre-approve the additional home health services. You say that it is felt that the enrollee 
needs nurses to come regularly due to her wound and her failing kidneys. The Plan denied your request. The 
Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. 
Our reviewer says that the requested number of visits is not medically reasonable and necessary. Our physician 
reviewer found the enrollee has poor mobility with a feeding tube. She has a full thickness wound which 
improved with a wound vacuum. The enrollee's care giver is able to provide the wound care per nursing note 
from June 21, 2023.  
 
There is no longer a medical need for skilled nursing wound care at this time. The visits approved by the Plan 
are sufficient to monitor the wound progress, but more than periodic checks are not required.  
 
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 additional home health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a total of 99 additional home health skilled nursing visits over two 
months.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services coded as 87150, 87481, 87798 and 87801 
provided May 17, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please review and process the claim towards 
payment. The Plan denied your request. The Plan says the service is considered not medically necessary. 
 
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 laboratory service have been met. 
The provided records included the 1-page laboratory requisition form. There were no other results or records 
provided to be able to determine medical necessity of the services provided. Therefore, we decided that the 
Plan does not have to pay for laboratory services coded as 87150, 87481, 87798 and 87801 provided May 17, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27125 billed for date of service September 8, 
2022. 
 
You asked the Plan to pay for procedure code 27125. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service billed. 
 
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 27125 is: Hemiarthroplasty, hip, partial (eg, femoral stem 
prosthesis, bipolar arthroplasty). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 27125. Our reviewer says that procedure 
code 27125 does not meet criteria for payment. Our reviewer found that the operative report does not describe a 
partial hip hemiarthroplasty. Procedure code 27125 describes a procedure in which the provider removes a 
damaged head of the femur and replaces it with a prosthetic device. This procedure was not documented in the 
operative report and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 27125 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 27125 billed for date of service September 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Treatment (IMRT) (77014x10, 
77386x10, G6002x10, G6015x10). 
 
You asked the Plan to pre-approve IMRT. You say that the requested treatment is needed for the enrollee's 
metastatic ductal carcinoma involving the brain lesions. The Plan denied your request. The Plan says that the 
special radiation and imaging would only apply for the cancer in the brain. The special treatments would not be 
necessary for cancer in the bone. 
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has metastatic breast cancer to the brain and bone in the setting of triple-negative 
(TN) right breast cancer. The IMRT is medically necessary for MF-SRT (multi-fractionated stereotactic 
radiotherapy) of brain metastases, especially in this case with 3 brain metastases. It is considered a standard of 
care and must be approved. Given the location of the lesions in the brain, their size, and dose and type of 
radiation treatment (30 Gray (Gy) in 5 fractions using MF-SRT), the daily image-guided radiation therapy 
(IGRT) using daily cone-beam computed tomography (CBCT) is medically necessary for radiotherapy (XRT) 
delivery to ensure the safety and accuracy of XRT delivery and 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 IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity Modulated Radiation Treatment (IMRT) (77014x10, 77386x10, G6002x10, G6015x10).  
 
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 procedure code 37228 billed for date of service February 8, 
2023. 
 
You asked the Plan to pay for procedure code 37228. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service billed. 
 
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 37228 is: Revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 37228. Our reviewer says that procedure 
code 37228 does not meet criteria for payment. Our reviewer found that the operative report does not include 
documentation of revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, 
initial vessel; with transluminal angioplasty. Procedure code 37228 is a surgical procedure in which the 
provider places a balloon catheter at the site of an occlusion in the blood vessel and inflates the balloon to 
expand the lumen of the vessel. This procedure was not found in operative report and therefore cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 37228 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 37228 billed for date of service February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair. 
 
You asked the Plan to pre-approve a bath/shower chair and rolling chair. You say that the clinical condition of 
the enrollee severely limits their ability to ambulate. You also say that the shower chair will greatly benefit the 
enrollee and assist them with activities of daily living their home such as bathing. 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 pre-approve a bath/shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic - resin with predominantly base metal 
(D6251) and (D0001). 
 
You asked the Plan to pre-approve the extraction, pontic - resin, and the dental service represented by code 
D0001. You say that the pontic service should be covered under the recement crown or bridge benefit. The 
Plan denied your request. The Plan says the pontic - resin, and dental code D0001 are not covered under the 
benefit package.  
 
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, these services are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the pontic - resin 
with predominantly base metal (D6251) and (D0001).