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

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided May 11, 
2023.  

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed. The definition of code 80307 is drug test(s), 
presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry 
analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, 
GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-
MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of 
service. 
 
Codes G0483 and 80307 remain not supported. The medical records provided are missing a lab 
order/requisition. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(80307 and G0483) provided May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig you purchased on April 14, 2023. 
 
You asked the Plan to pay for the wig. You say that you were told this item would be covered. The Plan denied 
your request. The Plan says wigs are not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig you purchased 
on April 14, 2023.  
 
Your complaint about Plan representatives giving you incorrect information via phone is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Treatment (PBT) (77014, 77523, G6002). 
 
You asked the Plan to pre-approve PBT. You say that the treatment is medically necessary. The Plan denied 
your request. The Plan says there are not enough studies on proton beam therapy for the enrollee's cancer to 
show it is safe and effective. 
 
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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no level I evidence that proton beam therapy (PBT) in this enrollee provides a superior 
outcome compared to photon therapy. Photon therapy (e.g., using either electrons or orthovoltage with 
appropriate shielding) is safe and effective in this case. Different dose fractionation can/should be considered 
for this enrollee per guidelines (e.g., 60-66 gray (Gy) in 30-33 fractions or hypofractionated schedules). 
Therefore, PBT is not medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Treatment (PBT) (77014, 77523, G6002).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of a Minuteman device (22840 and 
22612). 
 
You asked the Plan to pre-approve the services. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested service is experimental/investigational. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman device is experimental. More research is needed. 
 
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 the placement of a Minuteman device (22840 and 22612).
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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the required services can be provided in an alternate 
setting.  
 
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 that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) home health occupational therapy visits 
(G0152 x8). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight (8) home health occupational therapy visits (G0152 x8).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided April 
12, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed. The definition of code 80307 is drug test(s), 
presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry 
analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, 
GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-
MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of 
service. 
 
Code G0483 remains no supported. The medical records submitted do not include a detailed physician order or 
signed lab requisition of the list of 22 or more drugs that needs to be tested to support the billed code. Code 
80307 remains not supported. The medical records submitted do not include a detailed physician order or 
signed lab requisition of the presumptive drug classes that needs to be tested to support the billed code. Based 
on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (80307 and G0483) 
provided April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endovascular aortoiliac aneurysm repair, associated 
procedures, and inpatient hospitalization (34705, 34812, 37253, 37252, 34714). 
 
You asked the Plan to pre-approve an endovascular aortoiliac aneurysm repair with inpatient hospitalization. 
You say that the enrollee needs to have stints put in arteries to increase blood flow to legs. The Plan denied 
your request. The Plan says the records do not show that either of the enrollee's aneurysms are large enough or 
are expanding fast enough to warrant repair. 
 
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 an endovascular aortoiliac aneurysm 
repair with inpatient hospitalization. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there are inconsistencies 
between the studies evaluating the degree of iliac arterial disease. The most recent computed tomography (CT) 
scan demonstrates widely patent aortoiliac and femoral arteries down to the popliteal arteries. Recent 
angiogram documents severe tortuosity to the aortic bifurcation and proximal iliac arteries; neither study 
suggests any common or external iliac artery stenosis on the right. There is no sign of limb threat. She was 
fairly recently evaluated for vascular clearance for orthopedic surgery to her left foot and deemed to have 
satisfactory perfusion to allow Achilles tendon surgery.  It does appear however, that the enrollee's anatomy is 
not conducive to simple endograft repair. Therefore, efforts to treat the aneurysm will likely significantly 
increase the enrollee's risks during treatment for claudication. This review is only addressing the medical 
necessity of the endograft aneurysm repair. Based on the evidence provided in the medical record, unable to 
overturn the health plan determination. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an endovascular aortoiliac aneurysm repair with inpatient hospitalization have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an endovascular aortoiliac 
aneurysm repair, associated procedures, and inpatient hospitalization (34705, 34812, 37253, 37252, 34714).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99291 and 99053 billed for date of service January 2, 
2023. 
 
You asked the Plan to pay for codes 99291 and 99053. You say that the medical records support the level of 
service billed. The Plan denied your request. The Plan says code 99291 is not supported by the medical records. 
The records do not support 30-74 minutes of critical care.  The Plan also says that code 99053 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. In this case, the CPT Code Manual definition of 
code 99291 is critical care, evaluation and management of the critically ill or critically injured patient for the 
first 30-74 minutes. 
 
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 codes 99291 and 99053. Our reviewer says that code 99291 
is not supported by the medical record. Our reviewer found there was no documentation within the medical 
records supplied supporting the billing of this critical care evaluation and management service. 
 
In relation to code 99053, Medicare rules state that codes with a status indicator of B are always bundled and 
no separate payment is made. We find that procedure code 99053 has a status indicator of B on the Physician 
Fee Schedule. This means that procedure code 99053 is not separately payable. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99291 and 99053 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 99291 and 99053 billed for date of service January 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee's condition is life 
threatening and if they do not receive the equipment, it would put them into a risk of serious harm and 
mobility. The Plan denied your request. The Plan says 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 is not medically necessary. Our physician reviewer found that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. Although the enrollee was 
previously treated with a CPAP, they could also be treated with a BiPAP with AVAPS. Additionally, there is 
no documented failure of a BiPAP or BiPAP with AVAPS. Therefore, the elements of the coverage criteria are 
not satisfied, and 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 21, 
2023. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nalu peripheral nerve stimulator (PNS) system (64555 
x2, 64590, L8679 and L8680 x16). 
 
You asked the Plan to pre-approve the service. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the clinical value and effectiveness of Nalu PNS system in the setting 
of chronic knee pain syndrome secondary mononeuropathy with request to treat the superomedial and 
superolateral genicular nerves have not been demonstrated in the peer-review literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental and investigational therapy. There is insufficient evidence of long term efficacy of this therapy. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nalu peripheral nerve stimulator (PNS) system (64555 x2, 64590, L8679 and L8680 x16).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (TKA) (27447). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has trialed conservative treatments. 
You also say this is medically necessary for the enrollee. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding attempts at provider-supervised weight loss 
efforts. The previous weight was not clearly documented on the September 15, 2023, exam to corroborate 
weight loss efforts producing results with a weight of 137.4 kg (45.91 BMI) on the October 2, 2023, exam. There are inherent risks of performing total knee arthroplasties with an elevated body mass index of greater 
than 40. The provider did not clearly document significant factors and/or rationale for proceeding with the 
procedure despite BMI-related peer-reviewed literature results. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the requested total knee arthroplasty (TKA) is not medically reasonable or 
necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total knee arthroplasty (TKA) (27447).