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

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on April 4, 2023. 
 
You asked the Plan to pay for the bacterial urine culture. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with a diagnosis code 
which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes E0143 and E0156 provided on April 4, 
2023. 
 
You asked the Plan to pay for procedure codes E0143 and E0156. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the documentation provided 
does not support the services billed. 
 
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 procedure codes E0143 and E0156 
have been met. There were no medical records submitted for review. Therefore, we decided that the Plan does 
not have to pay for procedure codes E0143 and E0156 provided on April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator for 9 additional months. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee requires total volume, 
inspiratory time, and pressure support. The Plan denied your request. The Plan says that a home ventilator is 
not medically necessary for this patient because their needs can be met with an alternative device such as a 
BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system for 9 additional months is medically necessary. Our physician reviewer 
found that the enrollee has COPD and chronic respiratory failure necessitating a tracheostomy. The enrollee 
also should continue on the home ventilator system at the prior settings , and to change that would not be a 
standard of care. Therefore, the documentation supports the continued use of a home ventilator. 
 
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 system. have been met. Therefore, we decided that the Plan 
has to pre-approve a home ventilator system for 12 months.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided 
December 20, 2022, to January 4, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says a pneumatic compression device 
is not covered by Medicare to prevent deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided December 20, 2022, to January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99232 billed for dates of service January 27, 2023, to 
January 29, 2023. 
 
You asked the Plan to pay for code 99232. You say that the medical records indicate the dictation and 
transcription dates and times. The Plan denied your request. The Plan says the actual dates of service of the 
billed codes are not documented in the medical record. 
 
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 99232 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, the actual date of service is 
not documented in the medical records.  While the dictation and transcription times are provided, there is no 
evidence that these dates and times are contemporaneous to the actual rendering of the services. Based on this 
information, we decided that Medicare rules for coverage of code 99232 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99232 billed for dates of service January 27, 2023, to 
January 29, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the infectious agent detection by nucleic acid for Neisseria gonorrhoeae 
provided on March 1, 2023, billed with code 87591. 
 
You asked the Plan to pay for the billed code 87591. You say that the testing should be approved.  The Plan 
denied your request. The Plan says that all codes were approved aside from 87591. This was denied because 
the panel is not covered by Medicare.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a valid denial rationale in this case. It is noted that 
this code was denied because the panel is not covered. However, the Plan determined that payment should be 
made for the 9 other codes billed on this claim. No rationale for denying this specific code out of the 10 billed 
was provided. The records clearly show that this pathogen was tested as part of this panel.  Therefore, we 
decided that the Plan has to pay for the infectious agent detection by nucleic acid for Neisseria gonorrhoeae 
provided on March 1, 2023, billed with code 87591.  
 
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 drug testing services (G0480, 80307, 83789) provided on 
January 16, 2023. 
 
You asked the Plan to pay for drug testing services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says codes G0480 and 80307 cannot be verified by the 
records provided, and code 83789 is 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 CPT code. The rules say that providers performing validity 
testing on urine specimens utilized for drug testing should not separately bill the validity testing. 
 
In this case, we have confirmed that the CPT Code Manual definition of code 80307 is drug test(s), 
presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry 
analyzers, chromatography, and mass spectrometry either with or without chromatography, includes sample 
validation when performed, per date of service. The CPT Code Manual definition of code G0480 is drug 
test(s), definitive, 1-7 drug class(es), including metabolite(s) if performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing services have not been met. Specifically, the records provided do not indicate that 
presumptive drug testing was requested on the physician order, and no results of any presumptive (screening) 
tests are provided. We cannot verify code 80307 as being performed. Although the records do include a 
separate form on file with the laboratory indicating the specific drugs requested for testing in the requested 
panel, the records support that drugs from more than 1-7 drug classes were tested in this case. This means that 
there is a more appropriate code than G0480 to report for the definitive drug testing provided. In addition, 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 drug testing services (G0480, 80307, 83789) provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on May 10, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you are unable to afford the cost 
share applied. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $47.11 for an injection ($235.56 allowed x 20% = $47.11). This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for an injection provided on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 28, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pressure mattress and hospital bed (E0184, E0261) 
provided on May 3, 2023. 
 
You asked the Plan to pay for the pressure mattress and hospital bed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The specific items 
are not itemized on the shipping documentation. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a pressure mattress and hospital bed (E0184, E0261) provided on May 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a stated diagnosis of 
osteoporosis. The Food and Drug Administration (FDA) states that Reclast is indicated for the enrollee's 
condition. She had a normal bone density scan in 2021. The records are insufficient to establish a diagnosis of 
osteoporosis and that the Reclast is medically necessary and safe and effective. 
 
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 pre-approve Reclast.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve SI joint RFA. You say that you need this to improve your quality of life. 
The Plan denied your request. The Plan says this procedure is considered not medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that SI joint RFA is not considered reasonable and 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76706-26 billed for date of service February 
24, 2023. 
 You asked the Plan to pay for procedure code 76706-26. You say that this code should not be bundled with any 
other procedure code. The Plan denied your request. The Plan says payment for code 76706-26 is bundled into 
payment for code 76770-26. 
 
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 
76706-26 is a column II code to column I code 76770-26. 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. 
Therefore, we decided that the Plan does not have to pay for procedure code 76706-26 billed for date of service 
February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months continued use of a home ventilator 
(E0466). 
 
You asked the Plan to pre-approve 9-months continued use of a ventilator. You say that you are requesting 
reconsideration and have submitted medical records for review. The Plan denied your request. The Plan says 
the request for continued use of a ventilator is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 9-month continued use of a ventilator. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has chronic respiratory failure from obesity hypoventilation syndrome with 
restrictive physiology. The record indicates that the enrollee was successfully treated with a device in average 
volume-assured pressure support (AVAPS) mode. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability and failure of such a device has not been 
documented. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9-month continued use of a ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve nine (9) months continued use of a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 April 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 35820 billed for date of service August 25, 
2022. 
 You asked the Plan to pay for procedure code 35820. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 35820 is bundled into payment for code 33405. 
 
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 35820 
is a column II code to column I code 33405. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 35820 billed for date of service August 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Synvisc/Synvisc-One first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyalgan. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of knee. The requested medication is a new start.  The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.