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

 
We decided that the Plan does not have to pay for home health care provided from January 2, 2023, to January 
18, 2023. 
 
You asked the Plan to pay for home health care. You say that type of bill 0343 is correct and should be paid. 
The Plan denied your request. The Plan says this claim was not submitted with an appropriate type of bill. 
 The Plan must follow Medicare rules. Medicare rules say that home health prospective payment system claims 
must be billed with type of bill 0327, 0328, or 0329 depending on the circumstances.  
 
We looked at the file and Medicare rules. This claim was billed with type of bill 0343 which is not acceptable. 
Based on this information, we decided that Medicare rules for coverage of home health care have not been met. 
Therefore, we decided that the Plan does not have to pay for home health care provided from January 2, 2023, 
to January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there was no home assessment, seven element order, face to face examination, 
physician-signed detailed product order, or physical/occupational therapy assessment performed. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee would not be considered safe to operate a power wheelchair. There is no 
evidence that multiple power drives are necessary. The records do not address subsequent care or current 
functional status or capacity to safely operate a power 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that authorization is not required for this service. The 
Plan denied your request. The Plan says out-of-network services require authorization. 
 
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 an office visit provided on January 17, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service February 17, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that the services provided by the physician are 
separately identifiable. 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 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. Code 99232 is a per diem code. The record shows both codes were billed for the 
same provider, same date of service, and same diagnosis. 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 99232 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99232 billed for date of 
service February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT) 
(G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the requested radiation is 
needed to see how deep the cancer was gotten. The Plan denied your request. The Plan says there is not enough 
evidence that this type of radiation therapy guidance is needed or effective for your skin cancer. Therefore, it is 
not considered standard of care. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually, IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to you for which the 
target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a 
need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not 
unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound though that 
in and of itself does not mean that daily imaging is necessary but simply that the device was designed to 
incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a technology for 
which need has not been established by published data or supported by consensus guidelines (many of which 
recommend against treatment with these devices in general) is not necessary. The decision is unfavorable as 
billing for daily IGRT which would not be furnished in accordance with accepted standards of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT) (G6001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 9, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an Optimizer System Implantable Pulse 
Generator (0408T). 
 
You asked the Plan to pre-approve the insertion of an Optimizer System Implantable Pulse Generator. You say 
that this is medically necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of an Optimizer System 
Implantable Pulse Generator. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested device remains the subject of 
multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. At this time, it is considered 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 the insertion of an Optimizer System Implantable Pulse Generator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an Optimizer 
System Implantable Pulse Generator (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation (RFA) rendered 
on February 1, 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 services were 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. He 
underwent RFA of the genicular nerves after diagnostic blocks that provided 80 percent pain relief. Genicular 
ablation is the subject of ongoing clinical trials and is considered experimental in nature. The services were 
therefore not reasonable or 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. Therefore, we decided that the Plan does not 
have to pay for the genicular nerve radiofrequency ablation (RFA) rendered on February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease in the lower thoracic spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet coverage criteria. Our physician reviewer found the enrollee has not been 
hospitalized due to pain and the pain is noted to be severe. There is no progression of vertebral body height 
loss, kyphotic deformity, or severe limitation on her activities of daily living. Additionally, there is plausible 
multifactorial thoracolumbar pain. The most recent computed tomography scan also demonstrated retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service December 
24, 2022.  
 
You asked the Plan to pay for procedure code 99284. The Plan denied your request. The Plan says payment for 
code 99284 is bundled into payment for code 99223. 
 
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 99284 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 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 code 99284 billed for date of service December 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
x2, pontic - porcelain/ceramic (D6245), retainer crown - porcelain/ceramic (D6740) x2 and retainer crown - 
porcelain fused to noble metal (D6752). 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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. This benefit includes the 
requested pontic and retainer crown but is limited to one procedure code every five calendar years. Core 
buildup, including any pins when required is not covered under the Plans dental benefits. 
 
We looked at the file, the Plans rules, and Medicares rules. The record shows you have been pre-approved for 
pontic  cast noble metal (D6212) and retainer-crown  full cast noble metal (D6792) with service dates of 
June 22, 2023, to September 20, 2023. Although these are different services, they fall within the same category 
in your Evidence of Coverage and are subject to the same frequency limitations. Therefore, we decided that the 
Plan does not have to pre-approve pontic - porcelain/ceramic (D6245), retainer crown - porcelain/ceramic 
(D6740) x2 and retainer crown - porcelain fused to noble metal (D6752).  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required (D2950) x2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair provided on November 13, 2022. 
 
You asked the Plan to pay for manual wheelchair. You say that you are requesting reimbursement. The Plan 
denied your request. The Plan says this provider is not certified to participate in Medicare so is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment, a provider or supplier must 
be enrolled in the Medicare provider.  
 
We looked at the file and Medicare rules. This equipment supplier is not enrolled in Medicare so is not payable. 
Based on this information, we decided that Medicare rules for coverage of manual wheelchair have not been 
met. Therefore, we decided that the Plan does not have to pay for a manual wheelchair provided on November 
13, 2022.
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 October 3, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have submitted medical records to 
support payment. 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 October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim crown - further treatment or completion of 
diagnosis necessary prior to final impression (D2799). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of dental 
services. The Plan denied your request. The Plan says this service is not covered under your Plan. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Interim crown - further 
treatment or completion of diagnosis necessary prior to final impression (D2799) is not covered under the 
Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2799 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an interim 
crown - further treatment or completion of diagnosis necessary prior to final impression (D2799).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim denied due to being out-of-network.  
However, you had an order from the referring provider. The Plan denied your request. The Plan says you billed 
with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 13, 2022.
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 March 1, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that it was the surgeon's obligation to get 
authorization for these services. 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 March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional accessories for a prosthesis (L5968, L5981). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested K3 components exceed the enrollee's needs and cannot be approved. 
 
The Plan must follow 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 to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has been dependent on crutches for some time and ambulated at K3 level prior to 
surgery despite failed ankle fusion. The records support the enrollee is likely to be a K3 ambulator. the plan has 
incorrectly denied the plan asserting the enrollee is a K2 ambulator. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve additional accessories for a prosthesis (L5968, L5981).  
 
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 BostonGene Tumor Portrait (81455) provided on 
December 30, 2022. 
 
You asked the Plan to pay for the BostonGene Tumor Portrait. You say that this test was medically necessary 
and appropriate. The Plan denied your request. The Plan says this test was 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 pay for the BostonGene Tumor Portrait. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found molecular testing will not find actionable mutations in small cell cancer. 
 
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 BostonGene Tumor Portrait have not been met. Therefore, we decided that 
the Plan does not have to pay for the BostonGene Tumor Portrait (81455) provided on December 30, 2022.