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

 
We decided that the Plan does not have to pay for code 99233 billed for date of service December 30, 2022. 
 
You asked the Plan to pay for code 99233. You say that the medical records confirm this service was 
performed. The Plan denied your request. The Plan says code 99233 is not supported by the medical record. 
The records don't support a detailed interval history, a detailed exam, or medical decision making of high 
complexity. 
 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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. 
 
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 code 99233. Our reviewer says that code 99233 is not 
supported in the medical records. Our reviewer found the patient is a 64-year-old female who was treated in the 
hospital. The documented history was brief and included the patient having pain from kidney stone, has 
positive urinalysis and is reluctant to have surgery. The physical was focused and unremarkable. The plan 
included a 'nothing by mouth' order, consider cystoscopy and/or lasertripsy (nonemergent). Code 99233 was 
billed. However, the records don't support a detailed interval history, a detailed exam, or medical decision 
making of high complexity to justify this code.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 3, 
2022. 
 
You asked the Plan to pay for the DME. 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 the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the 
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes 
place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Specifically, this claim was billed with the home POS code. The 
records show that the enrollee was an inpatient when the DME was provided. As such, the inpatient POS code 
should be reported. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
(DME) provided on May 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura cream. 
 
You asked the Plan to pre-approve Opzelura cream. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opzelura cream.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes C1769, C1887, C1894, 75630, 36217, 76937, J1644, 
J3010, J3490, and Q9967 for date of service December 1, 2022. 
 
You asked the Plan to pay for codes C1769, C1887, C1894, 75630, 36217, 76937, J1644, J3010, J3490, and 
Q9967. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be billed correctly.  
 
We looked at the file and Medicare rules. Review of the file shows that these items should not be separately 
billed on the ASC claim. Codes that have payment indicators of L1 and N1 are packaged service/item and 
separate payment cannot be made. Based on this information, we decided that Medicare rules for coverage of 
codes C1769, C1887, C1894, 75630, 36217, 76937, J1644, J3010, J3490, and Q9967 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes C1769, C1887, C1894, 75630, 36217, 
76937, J1644, J3010, J3490, and Q9967 for date of service December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration because 
the device is needed for the enrollee. The Plan denied your request. The Plan says the request for a non-
invasive ventilator (NIV) is not medically necessary because the documentation does not support that this 
device meets but does not exceed the enrollee's need. 
 
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. 
 
 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 service is not medically necessary. Our physician reviewer found the enrollee has 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 a volume assured pressure support mode (TTV-VAPS) 
with auto-EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support (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. As stated in the Local Coverage Determination 
(L33800): "Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment 
policy requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive 
airway pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) This means 
that products currently classified as HCPCS code E0465, E0466, or E0467 when used to provide CPAP or bi-
level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be 
paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions 
described in this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-
level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myoelectric prosthesis and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says physical therapy could be done in lieu of this device. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the has been using his right hand for his activities of daily living. The documentation does not 
indicate that the enrollee has had a trial of this device supporting that the device will be effective for the 
enrollee's left upper extremity condition.  
 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a myoelectric prosthesis and accessories.
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 February 22, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this lab testing should not be 
bunded with dialysis 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 
February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fundus photography (92250) provided on March 17, 2023. 
 You asked the Plan to pay for fundus photography. You say that this service should be covered. The Plan 
denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of fundus photography have not been met. Therefore, we decided that the Plan does not have to pay 
for fundus photography (92250) provided on March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 6, 2022, billed 
with code 87631 and 99072. 
 
You asked the Plan to pay for the services as billed. You say that all billed codes should be paid.  The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. In addition, code 99052 is not payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also say that codes with status indicator 
of B are bundled in payment for other rendered services. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. In addition, code 99052 has a status indicator of B on the Physician Fee Schedule. Based on this 
information, we decided that Medicare rules for coverage of the services as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on September 6, 
2022, billed with code 87631 and 99072.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography of the larynx (95865), standby 
service (99360), and continuous intraoperative neurophysiology monitoring (G0453) provided on January 17, 
2023. 
 
You asked the Plan to pay for intraoperative neurophysiology testing. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these services are not covered during a 
parathyroidectomy. 
 
The Plan follows Medicare rules. Medicare rules say that intraoperative monitoring is not medically necessary 
in situations where historical data and current practices reveal no potential for damage to neural integrity 
during surgery. 
 
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 intraoperative neurophysiology testing. Our reviewer says that the services at issue were not medically necessary. Our physician reviewer found 
parathyroid surgery does not have the potential for damage to neural integrity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraoperative neurophysiology testing have not been met. Therefore, we 
decided that the Plan does not have to pay for needle electromyography of the larynx (95865), standby service 
(99360), and continuous intraoperative neurophysiology monitoring (G0453) provided on January 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888-SH) provided on 
September 4, 2022.  
 
You asked the Plan to pay for non-covered ambulance mileage. You say that this should be paid by the 
enrollee. The Plan denied your request. The Plan says this processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare law contains a restriction that miles 
beyond the closest available facility cannot be billed to Medicare. Non-covered miles beyond the closest 
facility are billed with procedure code A0888. Ambulance claims may use the -GY modifier on line items for 
such non-covered mileage, and liability for the service will be assigned correctly to the beneficiary. 
 We looked at the file and Medicare rules. Code A0888 was used to report non-covered miles and was not billed 
with modifier -GY. Based on this information, we decided that Medicare rules for coverage of non-covered 
ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay for non-
covered ambulance mileage (A0888-SH) provided on September 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 06, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that do not require authorization. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on February 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on October 12, 
2022. 
 
You asked the Plan to pay for the services. 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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested on the date of service in question. 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 the drug testing services (G0482) provided on October 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee has a specific clinical need. The 
Plan denied your request. The Plan says the requested services are 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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has recurrent congestive heart failure (CHF). The CardioMEMS device was 
approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with CHF. 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. 
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 20, 
2022.  
 You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple exams on this date 
of service. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 20, 2022.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 the services are 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.