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

 
We decided that the Plan does not have to pay for codes A6196, A6220, A6010, and A6219 for date of service 
February 3, 2023. 
 
You asked the Plan to pay for codes A6196, A6220, A6010, and A6219. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the submitted medical records include a proof of delivery; however, the documentation does not 
include an itemized shipping invoice to indicate the specific supplies delivered. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for codes A6196, A6220, A6010, and A6219 for date of service February 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 4, 2022, to 
February 17, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted a claim to be 
processed. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 4, 2022. The NOA was not received by the Plan until June 17, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 4, 2022, to February 17, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 billed for date of service February 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that the chart was coded correctly. The Plan denied 
your request. The Plan says that diagnosis codes K76.0 and R17 should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and the rules. Diagnosis code K76.0 does have an Excludes1 note. Diagnosis code R17 is 
not among those excluded from diagnosis code K76.0. In the same way, diagnosis code R17 does have an 
Excludes1 note. Diagnosis code K76.0 is not among those excluded from diagnosis code R17. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure code 99285 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve VIA disc allograft intervertebral disc augmentation procedure. You say that 
the enrollee has suffered from chronic low back pain as evidenced by both bidline and paramidline back pain, 
referred somatic pain. The Plan denied your request. The Plan says this procedure is not supported by research. 
 
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 VIA disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with 
conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve VIA disc allograft intervertebral disc 
augmentation procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95816 billed for date of service April 6, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the report was corrected. The Plan denied your 
request. The Plan says the billed code is not supported. 
 
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 95816 is electroencephalogram (EEG); including 
recording awake and drowsy.  
 We find that CPT code 95816 is not supported in the medical record. There is a more accurate code that 
describes the testing provided. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
95816 billed for date of service April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom lightweight manual wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair is covered when specific 
criteria are met. The rules state that for equipment to be covered, it must be appropriate and needed for use 
inside the home. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of a stroke 
and polyneuropathy with resulting weakness. The wheelchair is being requested for use outside of the home. 
The documentation does not support that she is safely able to use and maneuver the requested custom 
wheelchair in her home environment; therefore, the requested mobility device 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 these services have not been met. Furthermore, the file shows that the 
wheelchair is being requested for use outside of the home, and Medicare does not cover this item for that use. 
Therefore, we decided that the Plan does not have to pre-approve a custom lightweight manual wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says this request is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the 
enrollee does not meet the coverage criteria for Botox. Our physician reviewer found the enrollee does not have 
a condition which is indicated for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. The review says that the enrollee has post 
right mastectomy radiation pain syndrome. This is not a condition which is an indication for coverage. Based 
on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Botox.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2023. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 14, 2022 to 
October 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from October 14, 2022 to 
October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator (E0466) is 
medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
home ventilator (E0466). 
 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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator (E0466). Our physician reviewer found provided 
records in this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. Provided records document that the home ventilator is being requested for use in average 
volume assured pressure support (AVAPS) mode which is a modality that could be provided by a bilevel 
positive airway pressure (BiPAP) device with 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. Provided records in this case do not 
provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as opposed to 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminectomy. 
 
You asked the Plan to pre-approve a percutaneous laminectomy. You say that the enrollee is an excellent 
candidate for this therapy as this case demonstrates the most minimally invasive, medically necessary 
treatment. The Plan denied your request. The Plan says the requested surgery is considered experimental and 
investigational. 
 
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 a percutaneous laminectomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to corroborate this procedure is as safe/effective as the standard treatments. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 percutaneous laminectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous laminectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 13, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 
87801 billed for date of service February 2, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87150, 
87481, 87641, 87653, and 87798 are bundled into payment for other codes. Code 87801 is not supported. 
 
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. We have confirmed that codes 87481, 87641, 87653, and 87798 
are column II codes to column I codes 87801 and 87150. The medical records provided do not show that the 
services billed with the -59 modifier is a distinct procedural service. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the submitted medical 
records do not contain sufficient information to support the billed code. Without identification and 
documentation of the organism that each unit of 87798 represents that was billed on the same claim, the 
multiple organisms represented by code 87801 cannot be confirmed. 
 
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 codes 87150, 87481, 87641, 87653, 87798, and 87801 billed for date of 
service February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the requested Minuteman procedure 
is medically necessary.  The Plan denied your request. The Plan says the requested Minuteman procedure is not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman procedure. Our 
reviewer says that the requested Minuteman procedure is not medically necessary.  Our physician reviewer 
found the Minuteman procedure is experimental. More research is needed 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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (84591) provided on April 14, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that these services were necessary. The Plan denied 
your request. The Plan says these services were not provided by or referred by a network provider. Out-of-
network care is only covered in certain limited circumstances, which have not been met in this case. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services (84591) provided on April 14, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
enrollee does not meet the LCD coverage criteria. Our physician reviewer found that the LCD criteria requires 
3 months of 50% pain relief, and that time has not yet passed. Therefore, the request is not medically 
reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service April 14, 
2023.  
 
You asked the Plan to pay for procedure code 88377. You say that these services are supported in the medical 
record. 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 88377 is 5. The MAI value for this code is 3. You billed 6 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 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve removal of torus mandibularis (D7473) and sedation services 
(D9239, D9243). 
 
You asked the Plan to pre-approve the dental services. You say that you feel that these services should be 
covered. The Plan denied your request. The Plan says that these services are not covered. 
 
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. The Plan did not provide a copy of the applicable Evidence of Coverage for this 
case. We asked for this document, but it was not provided to us. Without this information we cannot determine 
that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been 
adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their 
denial of payment in this case. Therefore, we decided that the Plan has to pre-approve removal of torus 
mandibularis (D7473) and sedation services (D9239, D9243).  
 
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.