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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need help with walking and can't use the 
restroom alone. The Plan denied your request. The Plan says the services you require are called custodial care. 
Custodial care helps you with daily needs such as dressing, bathing, getting in and out of bed, going to the 
bathroom, and eating. Custodial care is not a covered benefit under Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85025 provided on September 8, 2023. 
 
You asked the Plan to pay for procedure code 85025. You say that you would like the Plan to reconsider their 
denial of payment. 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 85025 is Blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count) and automated differential WBC count. 
 
We find that CPT code 85025 is not supported in the medical record. Specifically, the laboratory results do not 
include a CBC. There is a more appropriate code for WBC testing. Based on this information, we decided that 
Medicare rules for coverage of procedure code 85025 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 85025 provided on September 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection. 
 
You asked the Plan to pre-approve the electronic connection. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the notes do not show a medical need to control the 
power options through the joystick. 
 
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 electronic connection. Our reviewer 
says that the requested electronic connection is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested electrical accessory is not medically necessary as the enrollee does 
have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. Therefore, the reviewer found that the requested electronic connection 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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29822-XU-LT rendered on March 28, 2023. 
 
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 procedure code 29822-XU-LT is considered inclusive to CPT 23130. 
 
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 29822 is "Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular 
cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, 
bursal side of the rotator cuff, subacromial bursa, foreign body[ies])." 
 
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 enrollee was being treated for 
impingement syndrome of the left shoulder. The enrollee underwent an arthroscopy of the left shoulder with 
open acromioplasty, acromioclavicular joint excision, and possible rotator cuff repair on 3/28/23. The 
procedure details cite the distal clavicle and anterior third of the acromion were exposed. Using a saw, Bovie 
Cautery, and a towel clip, the distal clavicle was removed. After this procedure, the Derrach retractor was then 
placed in the subacromial space and using a saw and Bovie cautery the anterior third of the acromion and 
coracoacromial ligament were removed. A thorough bursectomy was performed. The documentation does not 
support CPT 29822: arthroscopy, shoulder, surgical; debridement, limited 1 or 2 discrete structures (humeral 
bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor 
complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial 
bursa, foreign body[ies]) as a separate and distinct procedure from CPT 23130: acromioplasty or 
acromionectomy, partial, with or without coracoacromial ligament release. The bursectomy was essentially part 
of the overall partial acrominectomy procedure. 
 
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 procedure code 29822-XU-LT rendered on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration (D4266) provided on August 23, 
2023. 
 
You asked the Plan to pay for guided tissue regeneration (D4266). You say that this will help for future 
placement of an implant. The Plan denied your request. The Plan says this code is to be used with natural teeth 
only.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the code submitted is inappropriate for 
the service rendered. Specifically, this code is to be used only on natural teeth; however, the records show this 
service was provided at extraction sites. Therefore, we decided that the Plan does not have to pay for guided 
tissue regeneration (D4266) provided on August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 4, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy provided by a chiropractor 
on July 24, 2023, to August 21, 2023. 
 
You asked the Plan to pay for the mechanical traction therapy. You say that each time you visit the 
chiropractor's office your spine feels much better. The Plan denied your request. The Plan says the only 
covered chiropractic service is manual manipulation of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the mechanical traction therapy and the chiropractic manipulative treatment 
provided by a chiropractor on July 24, 2023, to August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87502, 87634 and 87798) billed for 
date of service August 7, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says these services were not billed appropriately, 
and these codes are not supported as requested by the enrollees treating physician. 
 
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 panel have been met. 
Specifically, the physician order is not signed, and there are no medical records or physician notes to support 
that this panel was requested by the enrollees treating physician and was medically necessary. In addition, the 
unsigned order indicates that one panel was requested, which should be billed with the most appropriate single-
unit panel code. Therefore, we decided that the Plan does not have to pay for the laboratory panel (87502, 
87634 and 87798) billed for date of service August 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate.  
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that the enrollee has ongoing back pain 
that has been worse over the past four years. You say that the enrollee has limited ambulatory ability due to the 
severe pain that goes into their buttocks and thighs. The Plan denied your request. The Plan says a bone 
marrow aspirate 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 a bone marrow aspirate. Our reviewer 
says that a bone marrow aspirate is not medically necessary. Our physician reviewer found that a bone marrow 
aspirate is considered experimental in spine surgery. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99070 and 97610 provided September 1, 
2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as 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, we have confirmed that code 97610 
is a column II code to column I code 11043. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Furthermore, we 
find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. 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 
procedure codes 99070 and 97610 provided September 1, 2023.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve power legrests. We decided that the Plan does not have to pre-
approve upgraded electronics.  
 
You asked the Plan to pre-approve power legrests (E1012), and upgraded electronics (E2310, E2313, E2377). 
You say that the power wheelchair ordered in 2021 was canceled and never delivered. The Plan says that the 
records do not show that you need power leg lifts. The Plan also says that the records do not show a medical 
need to control the power options through the joystick. 
 
We decided that the Plan has to pre-approve power legrests.  
 
The Plan follows Medicare rules. Medicare rules say that power options may be covered when certain 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 the item/service at issue. Our reviewer 
says that the requested power legrests are medically necessary. Our physician reviewer found the provided 
records indicate that the enrollee is not able to bend their legs at a 90-degree angle. The reviewer also found 
that the enrollee has 2+ ankle edema. Therefore, the reviewer found that the requested power legrests are 
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 power legrests have been met. Therefore, we decided that the Plan has to 
pre-approve power legrests.  
 
We also decided that the Plan does not have to pre-approve upgraded electronics. 
 
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 item/service at issue. Our reviewer 
says that the provided records indicate that the enrollee has adequate strength to manage standard power drives. 
Therefore, the reviewer found that the requested upgraded electronics 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 upgraded electronics at issue have not been met. Therefore, we decided that 
the Plan does not have to pre-approve upgraded electronics. 
 
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 pay for procedure codes 22853 and 20930 billed for date of service April 25, 2023.

You asked the Plan to pay for procedure codes 22853 and 20930. You say that you have provided medical records to support payment. The Plan denied your request. The Plan says payment for code 22845 is bundled into payment for code 22853. The Plan also says that code 20930 is never separately paid.

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 22845 is a column II code to column I code 22853. This claim has not been billed with an appropriate modifier to bypass the edit. In relation to code 20930, this code has a status indicator of B on the Medicare Physician Fee Schedule. This means that code 20930 is not separately 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 codes 22853 and 20930 billed for date of service April 25, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5298) from Costco Wholesale. 
 
You asked the Plan to pre-approve hearing aids. You say that the items are necessary. 
The Plan denied your request. The Plan says hearing aids ordered through providers other than 
the Plan Hearing are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only from the Plan Hearing.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids from Costco Wholesale have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hearing aids (V5298).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says neuropsychological testing is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the 
criteria listed in the Medicare rules section of this decision 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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that based on review of the records provided, this patient 
is being evaluated for pain evaluation. Based on the premise that this testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain 
including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, 
differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of 
central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous 
system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders, this patient does not meet the 
criteria for neuropsychological testing in that this patient has not received the workup for these tests, the tests 
rationale is not clear and is therefore not considered to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection, expandable controller, and 
harness. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is necessary to help the enrollee 
with activities of daily living (ADLs) and various medical needs throughout their daily life. The Plan denied 
your request. The Plan says the notes do not show a medical need to control the power options through the 
joystick. 
 
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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found an expandable controller is an electronic system that is capable of 
accommodating one or more additional features and can operate 3 or more powered seating options. The 
requested electrical accessories are not medically necessary as the enrollee does have use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. There is not a medical need for upgraded electronics. Therefore, the reviewer found that the 
requested upgraded electronics 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the electronic connection, expandable controller, and harness.