Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tracheostomy speaking valve provided on May 18, 2023. 
 
You asked the Plan to pay for the tracheostomy speaking valve. You say that you disagree with the Plan's 
denial. 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 physician order for the supplies provided in this case. Review of the file 
shows that a physician's order for the item rendered was dated for over two years ago. 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 the tracheostomy speaking valve provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on February 21, 2023, billed 
with codes 87481, 87491, 87500, 87529, 87563, 87591, 87625, 87640, 87641, 87653, 87661 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on February 21, 2023, billed with codes 87481, 87491, 87500, 87529, 87563, 87591, 87625, 
87640, 87641, 87653, 87661 and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alpha-Globin Gene Deletion or Duplication testing 
(81269). 
 
You asked the Plan to pre-approve genetic testing. You say that this test is medically necessary and 
appropriate. The Plan denied your request. The Plan says the requested test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Alpha-Globin Gene Deletion or Duplication testing (81269).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment (E0443, E1390, E0261, E0431, E0441) 
provided on May 9, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that the items were 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 physician order which supports medical necessity for the supplies provided 
in this case. The provided order does not specify start and end dates or the duration for which the oxygen 
supplies are needed. 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 oxygen 
equipment (E0443, E1390, E0261, E0431, E0441) provided on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99283 billed for date of service May 11, 2023. 
 
You asked the Plan to pay for code 99286. You say that the enrollee was seen for multiple diagnoses. The Plan 
denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 
G0168 provided on G0168. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99283 billed for date of service 
May 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36581, 37248, and 77001 billed for March 
21, 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 procedure codes 36581, 37248, and 77001 are 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 36581 is replacement, complete, of a tunneled centrally 
inserted central venous catheter, without subcutaneous port or pump, through same venous access. The 
definition of code 37248 is transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, 
including all imaging and radiological supervision and interpretation necessary to perform the angioplasty 
within the same vein; initial vein. The definition of code 77001 is fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance 
for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter 
with related venography radiologic supervision and interpretation, and radiographic documentation of final 
catheter position) (List separately in addition to code for primary procedure). 
 
We find that CPT codes 36581, 37248, and 77001 are not supported in the medical record. Specifically, there is 
no documentation of the final position of the tip of the central venous catheter to support code 36581. The file 
shows that disruption of the obstructive material (fibrin sheath) was performed and there is a more appropriate 
code for these services than 37248. Code 77001 is an add-on code that was not billed with a required primary 
procedure code. 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 procedure codes 36581, 37248, and 
77001 billed for March 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285-25 billed for date of service May 7, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the claim is not a duplicate. The Plan denied your 
request. The Plan says the claim processed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99285 was billed twice on the same day by providers of the same specialty who belong 
to the same medical group. If more than one evaluation and management service is provided on the same day 
by more than one physician in the same specialty in the same group, only one evaluation and management 
service may be reported Based on this information, we decided that Medicare rules for coverage of the billed 
service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285-
25 billed for date of service May 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that your doctor does not travel to your town. 
You say that you need to go to this appointment so you can continue your physical therapy. You also say that 
you do not have any other transportation options. The Plan denied your request. The Plan says additional 
mileage beyond what is allowed by the benefit is not covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20550 billed for May 10, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was processed correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that code 20550 was billed with the -LT modifier for 
laterality and was correctly paid at the Physician Fee Schedule rate for one side. Therefore, we decided that the 
Plan does not have to pay for procedure code 20550 billed for May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 27, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on February 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does not meet the Medicare 
criteria for LTACH services. The Plan denied your request. The Plan says the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
June 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. 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 urine polymerase chain reaction 
(PCR) panel rendered on June 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trunk brace rendered on May 19, 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 there is no itemized shipping/billing invoice. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the trunk brace rendered on May 19, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block (64454). 
 
You asked the Plan to pre-approve the service. You say that the enrollee reports that they have been suffering 
with knee pain for a long time and feels that they need relief. 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 this procedure is considered experimental/ investigational. There are ongoing clinical trials of 
this procedure in enrollee's who are status post total knee replacement. 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 genicular nerve block (64454).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023, to April 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion (0775T). 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 sacroiliac joint fusion. 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 sacroiliac joint instability, fracture, or lesion. Sacroiliac joint fusion for 
degenerative back pain is 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 sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint fusion (0775T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on October 2, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on October 2, 2022.  The Plan denied your request. The Plan says the medical records do 
not support the billing of code 99223 provided on October 2, 2022.  
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223 provided on October 2, 2022. Our reviewer found the 
documentation supports a comprehensive exam, but not a comprehensive history or medical decision making of 
high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on October 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 
rendered on January 22, 2023, to February 10, 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) coded E0675 rendered on January 22, 2023, to February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a dynamic custom carbon fiber ankle-foot orthotic (L2999). 
 
You asked the Plan to pre-approve a dynamic custom carbon fiber ankle-foot orthotic (L2999). You say that 
the requested dynamic custom carbon fiber ankle-foot orthotic is medically necessary. The Plan denied your 
request. The Plan says that the requested dynamic custom carbon fiber ankle-foot orthotic is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a dynamic custom carbon fiber ankle-
foot orthotic (L2999). Our reviewer says that the requested dynamic custom carbon fiber ankle-foot orthotic is 
medically necessary. Our physician reviewer found the physician and Certified Prosthetist/Orthotist (CPO) 
notes document this enrollees right ankle weakness and function-limiting pain, as well as the pathophysiology 
of this condition. Based on this complete record, there is no doubt that the additional functional ankle 
movement imparted by the requested custom fabricated brace and the dynamic ankle joint support element 
satisfies the specific provisions not only of the LCD/Policy Article - if considering this item equivalent to a 
concentric adjustable torsion joint - but it also satisfies the reasonable and necessary criteria from the Program 
Integrity Manual, Ch 13 as a generally coverable not otherwise specified (NOS) code for this enrollee in this 
circumstance. Therefore, the requested L2999 (the posterior dynamic element strut) should be approved for 
coverage. 
 
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 dynamic custom carbon fiber ankle-foot orthotic (L2999) have been met. 
Therefore, we decided that the Plan has to pre-approve a dynamic custom carbon fiber ankle-foot orthotic 
(L2999).  
 
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.