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

 
We decided that the Plan does not have to pay for procedure code 99285 provided on November 15, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 
 
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 99285. Our reviewer says that the medical 
records do not support the billing of code 99285. Our reviewer found the documentation from this date 
describes the enrollee suffering an ankle injury (inversion) after falling down 2 steps. She was able to climb 
stairs and ambulate but with pain. The physical examination was detailed including ankle swelling and 
tenderness, normal sensation, normal pulses, and nontoxic. Imaging showed fractures of distal tibia and fibula 
with disruption of the ankle mortise. The plan included splinting and surgery later in the week. The enrollee's 
vitals were stable. The documentation supported a detailed history and physical but not comprehensive 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 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on November 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are being charged for 
an ambulance ride in between hospitals. 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 a $275 
copayment for each one-way Medicare-covered ambulance transport.  
 
You have been asked to pay a $275 copayment for the ambulance services. This item/service falls within the 
ambulance services 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 copayment for the ambulance 
services provided on February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transthoracic echocardiography (procedure code 93306) 
rendered on November 8, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported. Our reviewer found that the medical records do not support 99306 being 
performed 11/8/2022. The procedure was ordered in February of 2022 and performed later after 11/8/2022. 
 
We looked at this coder'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 pay for a transthoracic echocardiography (procedure code 93306) rendered on November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
November 21, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that these services were reported 
appropriately and are supported in the medical record. The Plan denied your request. The Plan says these codes 
are not supported for separate reporting in this case. 
 
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 87481 and 87653 is a column II code to column I code 87801; 
however, 87481 and 87653 was 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 87481 and 87653. Our reviewer says that 
these services are not supported in the medical record. Our reviewer found although these services were 
performed, they were reported with a multiple organisms procedure code, which would include these services. 
There is no evidence to support that these services qualify for separate reporting or that the XU modifier was 
used appropriately in this case. 
 
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 87481 and 87653 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service November 
21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cerapedics I-factor allograft (20930). 
 
You asked the Plan to pre-approve Cerapedics I-factor allograft. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of Cerapedics I-factor, in the 
setting of lumbar spine fusion surgery have not been demonstrated in the peer-reviewed 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 Cerapedics I-factor allograft. Our 
reviewer says that the requested items/services are 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. Further studies are 
needed to corroborate that the requested allograft would be as safe or better than standard allograft procedures. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cerapedics I-factor allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cerapedics I-factor allograft (20930).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging service (71275) provided on January 23, 2023. 
 
You asked the Plan to pay for the imaging service. You say that this service was rendered in an appropriate 
place of service. The Plan denied your request. The Plan says this claim was submitted with an incorrect POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that for services provided to a patient who is registered inpatient or outpatient of a hospital, the 
correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS 
code or that of the appropriate outpatient hospital POS code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging service have not been met. Specifically, the claim for this service was submitted with 
POS code 22 (outpatient hospital). However, the medical records and claims history for this enrollee shows that 
they were registered inpatient status from January 21, 2023, to January 27, 2023. This means that the 
appropriate POS code to report for this service would be that of the appropriate inpatient POS code. Therefore, 
we decided that the Plan does not have to pay for the imaging service (71275) provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a powered upper extremity range of motion assist 
device (MyoPro Motion G) (L8702).  
 
You asked the Plan to pre-approve the device. You say that you believe the MyoPro should be considered for 
approval for patients like the enrollee who have exhausted all other options throughout their traditional course 
of rehabilitation.  The Plan denied your request. The Plan says there is lack of clinical evidence demonstrating 
an impact on improved health outcomes for MyoPro orthosis for home use, and the device is not medically 
appropriate. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve  a powered upper extremity range of motion assist device (MyoPro Motion G) (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 2, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim should not be denied for no 
authorization because the surgeon requested the anesthesia services. The Plan denied your request. The Plan 
says procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinary tract infection (UTI) report testing provided on 
October 24, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that molecular syndromic panels are covered for the 
indications established in the applicable LCD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 
91-year-old female with dysuria. A UTI Report was ordered. The requested UTI testing was not medically 
reasonable or necessary according to the coverage criteria in the LCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for urinary tract infection (UTI) report testing provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104 x2), 
surgical access to an implant body (D6011 x2), and custom fabricated abutments (D6057 x2). 
 
You asked the Plan to pre-approve bone graft at time of implant placement, surgical access to an implant body, 
and custom fabricated abutments. You say that the services are medically necessary. The Plan denied your 
request. The Plan says these services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
graft at time of implant placement (D6104 x2), surgical access to an implant body (D6011 x2), and custom 
fabricated abutments (D6057 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NuShield allograft for a surgical procedure. 
 
You asked the Plan to pre-approve NuShield allograft. You say that you want to resolve your pain. The Plan 
denied your request. The Plan says there is insufficient evidence-based medical literature to support this. 
 
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 NuShield allograft. Our reviewer says 
that the requested items/services are 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 to be a safe and/or effective treatment for the noted pathology. Further studies are needed to show the requested allograft is as safe and effective as other allografts. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NuShield allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve NuShield allograft for a surgical procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an at home visit provided on November 22, 2022.
 
You asked the Plan to pay for an at home visit. You say that the patient is homebound and cannot leave. This was the only way the provider would have been able to see this patient. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an at home visit provided on November 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve baseline polysomnography study and a continuous 
positive airway pressure (CPAP) study (95811, 95810).  
You asked the Plan to pre-approve baseline polysomnography study and a CPAP study. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sleep testing is covered when specific criteria 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 baseline polysomnography study and a 
CPAP study. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
reviewed documentation indicates that there is no documentation of observed apneas (stopped breathing), 
choking or gasping during sleep and, a completed and abnormal score on the Epworth Sleepiness Scale. The 
review has determined that s the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of baseline polysomnography study and a CPAP study have not been met. 
Therefore, we decided that the Plan does not have to pre-approve baseline polysomnography study and a 
continuous positive airway pressure (CPAP) study (95811, 95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options, accessories, attendant control, and expandable controller. 
 
You asked the Plan to pre-approve the attendant control and expandable controller. You say that the requested 
power wheelchair is necessary for the enrollee. The Plan denied your request. The Plan says the notes do not 
show a medical need to control the power options through the joystick. The Plan also says an attendant control 
cannot be covered if a user-operated control is requested. 
 
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 attendant control and expandable 
controller. Our reviewer says that the requested attendant control and expandable controller are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the provided documentation 
indicates that you have 3 out of 5 strength in your upper right extremity. The reviewer found that you have 
capacity to operate a wheelchair. Therefore, the reviewer found that the expandable controller is not medically 
necessary as the enrollee is able to manage standard power drives. The reviewer also found that an attendant 
control is not indicated when there is user control. 
 
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 attendant control and expandable controller have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options, accessories, attendant control, and expandable controller.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you strongly believe the enrollee would 
be best served in a higher level of care setting, and you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested LTACH admission is not medically 
necessary.  
 
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 that all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.