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

 
We decided that the Plan does not have to pay for therapy services (procedure code 97530) rendered from 
September 20, 2022 to September 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 97530 is "Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes." 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the therapy procedures 
documented do not include sufficient documentation to support the services billed. The records do not include 
the therapy provided, and therefore the code 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for therapy services (procedure code 97530) rendered from September 20, 2022 to September 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a disposable drug delivery system (A4305, A4223, A4221) 
provided April 15, 2023, to April 22, 2023. 
 
You asked the Plan to pay for a disposable drug delivery system. You say that your department requires 
reimbursement for the underpaid charges that are indicated on the claim that include the necessary supplies and 
service charges applicable to the medication being administered to the enrollee. The Plan denied your request. 
The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a disposable drug delivery system have not been met. Therefore, we decided that the Plan does not 
have to pay for a disposable drug delivery system (A4305, A4223, A4221) provided April 15, 2023, to April 
22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services performed on February 9, 2023, coded 
as 74240, 74230, 72040, 70100, and 70310. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because they were medically necessary and are supported in the records. The Plan denied your request. 
The Plan says the radiology services are denied because they were billed with an inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS. 
 
We looked at the file and Medicare rules. Codes 74240 and 74230 were performed in a mobile unit setting with 
the use of fluoroscopy. Therefore, they are not covered and are excluded under the portable x-ray provision. 
Codes 72040, 70100, and 70310 were billed with POS 21, indicating an inpatient hospital setting. However, 
documentation shows the radiology services were performed in a mobile setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services performed on February 9, 2023, coded as 74240, 
74230, 72040, 70100, and 70310.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87801 billed for date of service February 17, 2023. 
 
You asked the Plan to pay for procedure code 87801. You say that this testing was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says that this code represents one component of 
a multi-component code. Laboratory services should be reported with one code which covers all the laboratory 
services performed. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the code at issue covers testing for multiple organisms and may be 
used as a panel code. The Plan has not provided a clear explanation as to why this code was denied but many 
others on the same claim were paid. The Plan has not substantiated their denial in this case. Therefore, we 
decided that the Plan has to pay for procedure code 87801 billed for date of service February 17, 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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does not support 
that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Proteus wound Panel wound panel coded as 87641, 
87653, 87500, 87640, 87651, 87481 and 87798 provided October 12, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting review of the claim for 
reconsideration regarding payment on the tests performed. The Plan denied your request. The Plan says the 
request does not meet Medicare rules because the testing is not FDA approved nor has the testing undergone 
registration with Molecular Diagnostic Services Program (MolDX). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. This test is not FDA approved nor has the testing undergone 
registration with Molecular Diagnostic Services Program (MolDX). 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 Proteus wound Panel wound panel coded as 87641, 87653, 87500, 87640, 87651, 
87481 and 87798 provided October 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 74240, 74230, 72040, 70100, 
and 70310, billed on date of service January 19, 2023.  
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because they were medically necessary. The Plan denied your request. The Plan says the radiology 
services are denied because they were billed with an inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS. 
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 72040, 70100, and 70310 were billed with POS 11, 
indicating an office setting. However, documentation shows the radiology services were performed in a mobile 
setting. There is no evidence the services were provided in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services coded as 74240, 74230, 72040, 70100, and 70310, 
billed on date of service January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found you 
do not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative 
means of managing power drive. Power tilt/recline 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 a group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of Matrion skin substitute (15271, 
Q4201). 
 
You asked the Plan to pre-approve the application of Matrion skin substitute. You say that this skin substitute is 
medically necessary for the enrollee. The Plan denied your request. The Plan says this skin substitute is 
considered unproven and 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 application of Matrion skin 
substitute. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that in this particular case the enrollee has undergone right 
foot fifth ray surgery. Advanced skin substitute dressings are generally reserved for nonhealing diabetic ulcerations as well as nonhealing venous stasis ulcerations. They are not used a standard of care for fresh 
surgical wounds. It does not appear as though the enrollee has undergone enough time to allow the wound to 
heal. This should include dramatic offloading of the wound area, skin dressings including Aquacel, foam, etc., 
and systematic routine debridement of nonviable tissue from the wound. It does not appear that the advanced 
skin substitute Matrion is medically reasonable or necessary at this time. 
 
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 application of Matrion skin substitute have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the application of Matrion skin substitute (15271, Q4201).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on March 31, 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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered when specific criteria 
are met. 
 
We looked at the file and Medicare rules. The records show that the enrollee was not being considered for a 
repeat biopsy. 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 ConfirmMDx testing rendered 
on March 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar total disc arthroplasty (22860 x2). 
 
You asked the Plan to pre-approve lumbar total disc arthroplasty. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee is 85 years old, therefore lumbar disc arthroplasty is non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that LADR is non-covered for Medicare beneficiaries 
over 60 years of age.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lumbar total disc arthroplasty have not been met. Therefore, we decided that the Plan does not have 
to pre-approve lumbar total disc arthroplasty (22860 x2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits and 6 home health 
physical therapy 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 provided 
documentation does not describe a wound or other medical condition that would require nursing care. Health 
aide services can be considered. Also, the approved physical therapy sessions should suffice to help instruct 
and supervise the enrollee's strength training. If more therapy is needed following the completion of the 4 
sessions, additional sessions may be considered.  
 
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 2 home health skilled nursing visits and 6 home health physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for polycarbonate lens coating (V2784) provided on May 9, 2023. 
 
You asked the Plan to pay for polycarbonate lens coating. You say that you were told by the provider that they 
accepted your insurance and that these services would be covered with minimal cost to you. The Plan denied 
your request. The Plan says that they have agreed to pay for the other vision items/services as you were given 
incorrect information from a provider; however, the polycarbonate lenses were not billed correctly and must be 
resubmitted with the KX modifier. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The rules also 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. 

We looked at the file and the Plan's rules. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. The Plan is applying a rule 
implemented by Medicare which applies to Medicare-covered lenses following medically necessary cataract 
surgery. The eyeglasses at issue are not being paid for by Medicare, but they are covered by your supplemental 
benefit which exceeds Medicare coverage. Supplemental/routine eyewear is not subject to the same 
rules/policy as eyewear that is covered by Medicare, as these services are not considered medically necessary. 
The KX modifier is used when requirements specified by the medical policy have been met. These would never 
be met for supplemental eyewear; therefore, this rule does not apply. 
 
Polycarbonate lens coating is not explicitly excluded from coverage according to your contract with the Plan, 
and the total cost of the items purchased does not exceed your $300 annual benefit. In addition, if there is some 
sort of billing issue associated with this claim, then the liability would fall to the provider and is not your 
responsibility. The Plan has failed to provide a clear reason explaining why the polycarbonate lenses have 
remained denied but the rest of the claim overturned. The Plan has not substantiated their denial in this case. 
Therefore, we decided that the Plan has to pay for polycarbonate lens coating (V2784) provided on May 9, 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion. 
 
You asked the Plan to pre-approve minimally invasive percutaneous SI fusion. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the documentation does not support that 
the SI joint is the primary source of the enrollee's pain. 
 
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 minimally invasive percutaneous SI 
fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented SI joint instability fracture or 
lesion. SI joint fusion for degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of minimally invasive percutaneous SI fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbar spine 
(72100), mechanical traction therapy (97012), and the electrical stimulation (G0283) provided from May 30, 
2023, through June 9, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
  
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbar spine (72100), 
mechanical traction therapy (97012), and the electrical stimulation (G0283) provided from May 30, 2023, 
through June 9, 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 June 2, 2023. 
 
You asked the Plan to pay for procedure code 99100. You say that as an anesthesia provider, these services 
should be covered under the authorization for the surgeon/facility. 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 June 2, 2023.