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

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the panel testing played a relevant role in 
mutation identification. The Plan denied your request. The Plan says the code is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   

We looked at the file and the rules. The medical records provided do not show that code G0452, billed with the 
-59 modifier, was a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
G0452 billed for date of service November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided by an out-of-network (OON) provider 
from November 10, 2022, to December 8, 2022. 
 
You asked the Plan to pay for OON office visits. You say that these visits should be covered. The Plan denied 
your request. The Plan says these visits were not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that out-of-network 
services, including office visits, require prior authorization.  
We looked at the file and Medicare rules. The office visits at issue were not authorized. Based on this 
information, we decided that Medicare rules for coverage of OON office visits have not been met. Therefore, 
we decided that the Plan does not have to pay for office visits provided by an out-of-network (OON) provider 
from November 10, 2022, to December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
September 7, 2022, and billed with codes 87481, 87640, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on September 7, 2022, and billed with codes 87481, 87640, and 87798.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service from 
January 1, 2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service from January 1, 2023, to January 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) paid for on April 7, 2022. 
 
You asked the Plan to pay for the sales tax. You say that you rely on the stair lift every day now, and you 
believe this has saved the Plan's money as well. The Plan denied your request. The Plan says this is a non-
covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make separate payment for 
sales tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999) paid for on April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical records show that there is no need for an intensive rehabilitation 
program.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45381 billed for date of service January 25, 
2023. 
 
You asked the Plan to pay for the billed services. You say that  medical records support the billing. The Plan 
denied your request. The Plan says the billed service cannot be verified. 
 
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 45831 is colonoscopy, flexible; with directed submucosal 
injection(s), any substance. We find that CPT code 45831 is not supported in the medical record. 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 45381 billed for date of service January 25, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 73610 and 73630 billed for date of service December 
26, 2022. 
 
You asked the Plan to pay for codes 73610 and 73630. You say that these services were medically necessary 
and provided emergently. The Plan denied your request. The Plan says these services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, 
meaning that they are STV-packaged services.  The disputed codes were billed on the same claim with a code 
that has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 73610 and 73630 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 73610 and 73630 billed for date of service December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72040, 74230, 70100 and 99204 billed for 
date of service January 10, 2023. 
 
You asked the Plan to pay for procedure codes 72040, 74230, 70100 and 99204. You say that you have 
correctly billed the services at issue. The Plan denied your request. The Plan says the services at issue have 
been billed with an inaccurate POS code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 72040, 74230, 70100 and 99204 are not supported. Specifically, the case record 
documents that the services at issue were provided by a mobile provider at a skilled nursing facility. The 
services were incorrectly reported with POS 11 indicating an office setting. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 72040, 74230, 70100 and 99204 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 72040, 74230, 70100 and 
99204 billed for date of service January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided November 14, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that this device was 
provided for use during the enrollee'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 a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided 
November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on November 29, 2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on January 14, 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 claim was not billed with correct diagnosis codes. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with diagnosis codes that 
exclude each other. 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 anesthesia services 
rendered on January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and related 
accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the requested 
power wheelchair and accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that you have a 
neurologic disorder with functional deficits. The documentation does not indicate that you have any pressure 
injuries or requires intermittent catheterization of the bladder or have spasticity that would necessitate power 
tilt or recline. Although your condition may meet criteria for a PWC, the criteria for this specifically requested 
PWC with power options including power tilt and recline are not met. Since the PWC base is not medically 
necessary, the requested accessories are not covered. 
 
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 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 (K0856) and related accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 3, 2022 to 
January 1, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 December 3, 2022 to 
January 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, cleaning, and unspecified 
preventive procedure (D1110, D0120, D1999) provided on August 12, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they did not fall 
within you plan benefits at the time. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation, 
cleaning, and unspecified preventive procedure (D1110, D0120, D1999) provided on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve E2311, E2313, and E2377. We decided that the Plan does not 
have to pre-approve E2300.  
 
You asked the Plan to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377). 
You say that this is medically necessary. The Plan says that it is not medically necessary to control the three 
requested power options through the joystick (drive interface). 
 
We decided that the Plan has to pre-approve E2311, E2313, and E2377.  
 
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 for E2311, E2313, and E2377. Our reviewer says that 
the enrollee is non-ambulatory and requires a power wheelchair for mobility and performing basic daily 
activities. The enrollee cannot perform pressure relief independently due to weakness and has a sacral pressure 
wound. The complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 
power wheelchair base. The expandable controller with harness and electronic connection are necessary to 
operate the group 3 power wheelchair base and the three power options, including, tilt, recline and elevating leg 
rests, via a joystick. 
 
 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 items have been met. Therefore, we decided that the Plan has to pre-approve 
E2311, E2313, and E2377.  
 
We also decided that the Plan does not have to pre-approve E2300. 
 
The Plan follows Medicare rules. Medicare rules say that E2300 is not covered because it is not primarily 
medical in nature. 
 
We looked at the file and Medicare rules. Items that are not primarily medical in nature are not covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of E2300 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve E2300. 
 
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: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve E2310, E2313, and E2377. We decided that the Plan does not 
have to pre-approve K0108x2.  
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power 
seating system motor (E2310), harness (E2313), expandable controller (E2377), integral knee pads (K0108 
x2).. You say that this is medically necessary. The Plan says that this is not medically necessary. 
 
We decided that the Plan has to pre-approve E2310, E2313, and E2377.  
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they are 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 for E2310, E2313, E2377. Our reviewer says that the 
requested electrical accessories are medically necessary as the enrollee is unable to operate and control the 
power options using the switches that are included in the basic wheelchair. 
 
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 items have been met. Therefore, 
we decided that the Plan has to pre-approve E2310, E2313, and E2377.  
 
We also decided that the Plan does not have to pre-approve K0108x2. 
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they have a primarily medical 
purpose. 
 
The requested knee pads do not serve a primarily medical purpose. Based on this information, we decided that 
Medicare rules for coverage of K0108x2 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve K0108x2. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on September 24, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99222 is included in the global surgery 
payment for procedure code 11721 provided on September 24, 2022. Separate payment cannot be made for 
procedure code 99222. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99222 have not been met.  Therefore, we decided that the Plan does not have to pay for procedure code 
99222 provided on September 24, 2022.