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

 
We decided that the Plan does not have to pre-approve orthopedic footwear (L3221). 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear (L3221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osteogensis stimulator (E0760), provided on June 19, 
2023. 
 
You asked the Plan to pay for the osteogensis stimulator. You say that the item 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, or relevant medical records which support medical 
necessity for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the 
osteogensis stimulator (E0760), provided on June 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pr-approve the ambulance service, basic life support, non-emergency 
transport. 
 
You asked the Plan to pr-approve transposition to physician appointments. The Plan denied your request. The 
Plan says transportation to a physicians office is not a covered destination. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of transposition to physician appointments have not been met. Therefore, 
we decided that the Plan does not have to pr-approve the ambulance service, basic life support, non-emergency 
transport.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a bone growth stimulator to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a bone growth stimulator to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization. 
 
You asked the Plan to pre-approve the outpatient procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is considered experimental and therefore is not 
covered. 
 
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 outpatient procedure. Our reviewer 
says that the requested genicular artery embolization is not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. While the 
studies are noted to be promising, further studies/research is needed to corroborate that geniculate artery 
embolization is as good as or better than standard treatments for knee osteoarthritis. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested genicular artery embolization 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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular artery embolization.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services described by code 70450 performed 
on date of service June 20, 2023. 
 
You asked the Plan to pay for 70450. You say that 70450 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 70450 is denied because it is not supported in the 
documentation. 
 
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 70450 is computed tomography (CT), head or brain; 
without contrast material. 
 
We find that CPT code 70450 is not supported in the medical record. Specifically, we confirmed the records provided do not contain an interpretation of a CT of the head or brain without contrast materials to support this 
service was performed. Based on this information, we decided that Medicare rules for coverage of 70450 have 
not been met. Therefore, we decided that the Plan does not have to pay for the radiology services described by 
code 70450 performed on date of service June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93319 billed for date of service December 
29, 2022.  
 
You asked the Plan to pay for procedure code 93319. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93319 is bundled into payment for code 93325. 
 
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 93319 
is a column two code to column one code 93325 with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93319 billed for date of service December 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve upper and lower dentures. 
 
You asked the Plan to pre-approve upper and lower dentures. You say that you would like dentures because 
you are having trouble chewing food. The Plan denied your request. The Plan says that there were no medical, 
emotional, physical, or psychosocial needs identified to support the need for dentures. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
 
  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 upper and lower dentures. Our reviewer 
says that the documentation does support that the requested dentures are necessary and reasonable to meet your 
needs and to improve and maintain your overall health status. Our physician reviewer found the dentist stated 
that 2 weeks after the extractions, the jawbone is still healing but healing well. The dentist states that at the 
time of the examination after extractions that the ridge was not ideal and may require alveoloplasty, and to re-
evaluate the bone after 3 months. Our reviewer found that this does not mean that you cannot have dentures or 
are contraindicated, but simply, another procedure may need to be done prior to having the dentures made to 
decrease risk of potential discomfort in the future with the dentures. When the jawbone is not smooth, these 
areas can be impinged upon while a person is eating with dentures, and sore spots can develop. A person is not 
able to adequately chew or eat their food without any teeth, and upper and lower complete dentures are 
medically necessary for these patients. Our physician reviewer also found that without the ability to chew, you 
will have digestive issues, and nutrients may not be absorbed well, causing health issues and nutrient 
deficiency. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upper and lower dentures have been met. Therefore, we decided that the Plan 
has to pre-approve upper and lower dentures.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99254 billed for date of service February 2, 
2023. 
 
You asked the Plan to pay for procedure code 99254. You say that the claim is billed correctly and should be 
paid. 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 99254 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99254 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99254 billed for date of service February 2, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve implantation of a Hypoglossal Nerve Stimulator. 
 
You asked the Plan to pre-approve implantation of a Hypoglossal Nerve Stimulator. You say that your BMI 
was 30.82 when taken in the office on July 20, 2023, and the central and mixed apneas equal 14.56% of the 
total Apnea-Hypopnea Index (AHI). The Plan denied your request. The Plan says that the medical records 
received from the provider did not show the enrollee having a BMI equal to or less than 35 and that the 
enrollee's central and mixed apneas are less than 25 percent of the total AHI of the provided sleep study. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of a Hypoglossal Nerve Stimulator is 
covered when the criteria in the Medicare rules section of this decision are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve implantation of a Hypoglossal Nerve 
Stimulator. Our reviewer says that implantation of a Hypoglossal Nerve Stimulator is medically reasonable and 
necessary in this case. Our physician reviewer found that based on the medical records provided there is 
documentation that the hypoglossal nerve neurostimulator at issue in this case meets all Medicare criteria for 
medically reasonable and necessary and safe and effective for you. The provided records in this case document 
moderate obstructive sleep apnea and a body mass index (BMI) less than 35 kg/m2 (BMI is 30.82 as of 
July 20, 2023). A polysomnography (PSG) was performed within 24 months of first consultation for 
Hypoglossal Nerve Stimulator implant; and you had predominantly obstructive events (defined as central and 
mixed apneas less than 25% of the total AHI - central and mixed events were 14.6% of the total AHI); and an 
AHI of 15 to 65 events per hour (were 27.3 events per hour); and the documentation that demonstrates 
continuous positive airway pressure (CPAP) failure or CPAP intolerance including shared decision making that 
you were intolerant of CPAP despite consultation with a sleep expert. The records show an absence of 
complete concentric collapse at the soft palate level as seen on a drug-induced sleep endoscopy (DISE) 
procedure (<75% collapse); and no other anatomical findings that would compromise performance of device.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a Hypoglossal Nerve Stimulator have been met. Therefore, we 
decided that the Plan has to pre-approve implantation of a Hypoglossal Nerve Stimulator.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy (G0152 x3). 
 
You asked the Plan to pre-approve home health services. You say that this is 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 clinical 
documentation shows that all appropriate home health occupational goals have been met. The records do not 
show that 3 additional home health occupational visits are required to effectively provide treatment, care, 
and/or services in order to improve your level of function, or to establish/perform a maintenance program to 
maintain your level of function and/or prevent deterioration. 
 
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 home health occupational therapy (G0152 x3).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502 and 87640 billed for date of service 
March 16, 2023. 
 
You asked the Plan to pay for procedure codes 87502 and 87640. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these codes are not 
supported for separate payment. 
 
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 codes 87502 and 87640 are column II codes to column I code 87633; 
however, 87502 and 87640 were each billed with a modifier.  
 
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 codes 87502 and 87640. Our reviewer says that 
these codes are not supported with modifier 59 for separate billing/payment. Our reviewer found the laboratory 
report does not include documentation to support the rationale of billing these services separately. Therefore, 
these codes and modifier cannot be verified. 
 
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 codes 87502 and 87640 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87502 and 87640 billed for date of service March 16, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 13, 2023, billed with 
codes 81209, 81223, 81250, 81305 and 81320. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 13, 2023, billed with codes 81209, 81223, 81250, 81305 and 81320.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 for date of service May 24, 2023. 
 
You asked the Plan to pay for procedure code 97530. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code at issue 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of procedure 
code 97530 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
97530 for date of service May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elastic knee strap (A4467) purchased on August 3, 2023. 
 
You asked the Plan to pay for the elastic knee strap. You say that the item was medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that elastic or other fabric support garments (A4467) 
with or without stays or panels do not meet the statutory definition of a brace because they are not rigid or 
semi-rigid devices. Code A4467 is denied as noncovered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the elastic knee strap have not been met. Therefore, we decided that the Plan does not have to pay 
for the elastic knee strap (A4467) purchased on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the provider you requested is in the Plan's 
network. The Plan denied your request. The Plan says that the provider is not in their network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel billed with codes 87631, 87651, 87653, 
87798, and 87637 for February 2, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a respiratory pathogen panel test must not be 
unbundled and billed as individual components regardless of the fact that the panel reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. The file shows that the panel was billed as unbundled codes and not 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 respiratory panel billed 
with codes 87631, 87651, 87653, 87798, and 87637 for February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on June 20, 2023. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the records do not support a lab order for the specific code billed on this 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic laboratory tests must be 
specifically ordered by the physician that is treating the enrollee.  
 
We looked at the file and Medicare rules. The record does not support a lab order for code G0483 specifically. 
Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on June 20, 2023.