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

 
We decided that the Plan has to pre-approve an expandable controller with harness and electronic connection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a history of a T10 spinal 
cord injury. He is non-ambulatory and uses a power wheelchair (PWC) for mobility and performing basic daily 
activities. He cannot perform pressure relief independently due to upper extremity weakness and he has a 
history of pressure wounds. He requires a PWC with power tilt and recline for adequate pressure relief and 
positioning. He requires power elevating leg rests for positioning of his lower extremities. The complexity of 
his seating and positioning needs necessitates a more complex group 3 power wheelchair base. The expandable 
controller with harness and electronic connection are necessary to operate the group 3 power wheelchair base 
and the three power options via a joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve an expandable controller with harness and electronic connection.  
 
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 three (3) additional visits of direct skilled nursing 
services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (G0299). 
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial and request 
reconsideration. 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 records 
provided are for the initial skilled visit on February 7, 2023. The Plan has not supplied records to support its 
denial. The request is not medically necessary because the records do not show that you require skilled nursing 
home health services any longer. 
 
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 three (3) additional visits of direct skilled nursing services of a registered nurse 
(RN) in the home health or hospice setting, each 15 minutes (G0299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93923 billed for date of service December 
28, 2022. 
 
You asked the Plan to pay for procedure code 93923. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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 93923 is: Complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements 
with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or 
more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with 
provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with 
reactive hyperemia). 
 
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 93923. Our reviewer says that procedure 
code 93923 does not meet criteria for payment. Our reviewer found that the provided procedure report does not 
include documentation to support a complete extremity arterial study. The procedure report describes a limited 
study. 
 
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 93923 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93923 billed for date of service December 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from November 6, 2022, to November 
16, 2022. 
 
You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says the enrollee no longer 
had skilled nursing facility needs  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from November 6, 2022, to November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back canes (K0108), custom platform (K0108), extra 
large platform (K0108), harness (E2313), expandable controller (E2377), and detachable armrest (E0973). 
 
You asked the Plan to pre-approve back canes, custom platform, extra large platform, harness, expandable 
controller, and detachable armrest. The Plan denied your request. The Plan says the requested back canes serve 
no medical purpose and are not covered. The Plan says the custom platform (K0108) and extra large platform 
(K0108) are incorrectly coded and unbundled. The Plan says there is not a medical need to control these power 
options through the joystick. The Plan also says armrests and their complete assembly (including any options) 
are already included with the approved power tilt and recline systems. 
 
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 custom platform, extra large 
platform, harness, expandable controller, and detachable armrest. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided records document that the enrollee has paraplegia (but not quadriplegia) and they have 3 to 
5 out of 5 bilateral upper extremity strength with no documentation from their physician that they have 
inadequate upper extremity strength and function to operate the wheelchairs power options with their own 
switches. Our reviewer found that the custom platform (K0108) and extra large platform (K0108) are not 
correctly coded (the correct code for footplates are K0040, K0041 or K0042). Our physician reviewer also 
found that the detachable armrest (E0973) is unbundled as armrests are included in the already approved power 
tilt/recline feature. 
 
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 custom platform, extra large platform, harness, expandable controller, and 
detachable armrest have not been met. 
 
Medicare rules also say that for equipment to be covered, it must primarily serve a medical purpose. The back 
canes (K0108) at issue in this appeal do not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve back canes (K0108), custom platform (K0108), extra large 
platform (K0108), harness (E2313), expandable controller (E2377), and detachable armrest (E0973).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection. The Plan denied your request. The Plan says 
although there is one approved power option on this wheelchair (power tilt), there is not a medical need to 
control this power option through the joystick. 
 
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 electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has left hemiplegia but is able to use a standard joystick with their right 
upper extremity. The enrollee has adequate strength to manage standard power drives. Our reviewer also found 
that an expandable controller is not medically necessary to meet the enrollee's needs. 
 
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 electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and one power seating 
system motor (E2310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chest strap (K0108) for a wheelchair. 
 
You asked the Plan to pre-approve a chest strap. You say that a chest strap is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says a chest strap is not reasonable and 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 a chest strap. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that a wheelchair accessory with an existing Healthcare Common Procedure Coding System (HCPCS) code may not be coded K0108. The requested strap has a HCPCS code, E0978. 
 
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 chest strap have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a chest strap (K0108) for a wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (U0005) provided on December 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as 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 U0005 is "Infectious agent detection by nucleic acid (dna 
or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), 
amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 
calendar days from date of specimen collection (list separately in addition to either code u0003 or u0004) as 
described by cms-2020-01-r2". 
 
We find that payment for CPT code U0005 is not supported in the medical record. Specifically, code U0005 was not billed with either code U0003 or code U0004 as required by the code definition. 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 the lab services (U0005) provided on December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81297 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 81297. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the payment for code 81297 is included in 
the payment for code 81295. 
 
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 81297 is a column II code to column I code 81295; however, 81297 
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 code 81297. Our reviewer says that the record 
does not support 81297 with modifier 59 as a separate and distinct procedure. Our reviewer found 81297 is a 
portion of 81295 and in this case, should not be reported separately. 
 
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 81297 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81297 billed for date of service December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade and 
electronic connection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have 
adequate strength in your arms to manage the standard power drives in the approved power wheelchair. The requested expandable controller with harness upgrade and electronic connection are not medically necessary at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller with harness upgrade and electronic connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4556, A4557, and A4630 billed for date of 
service December 8, 2022. 
 
You asked the Plan to pay for procedure codes A4556, A4557, and A4630. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says procedure code A4556, A4557, and A4630 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 codes A4556 and A4557 have a status indicator of P on the Physician Fee Schedule. 
These services were provided on the same day as a physician service. This means that procedure codes A4556 
and A4557 are not separately payable. Code A4630 is not separately allowed. This means this code is not 
payable as billed. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes A4556, A4557, and 
A4630 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
A4556, A4557, and A4630 billed for date of service December 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
November 08, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. You say that you disagree with 
the copayment. 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 $150 
copayment for outpatient diagnostic tests/all other duagnostic procedures and test. 
 
You have been asked to pay a $150 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/all other duagnostic procedures and test 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 an outpatient diagnostic tests provided on November 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96401) provided on October 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 96401 is "Chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic". 
 
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 use of code 96401 is 
not supported by the records provided. Our reviewer found that the procedure code reported cannot be verified, 
as no chemotherapy administration was documented in medical record. There is a more appropriate code to report for service provided. 
 
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 the services (96401) provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
purchased on February 6, 2023. 
 
You asked the Plan to pay for the CPAP device. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was obtained through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device purchased on February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Integrated BRACAnalysis (81432, 81433). 
 
You asked the Plan to pre-approve Integrated BRACAnalysis. You say that this test is critical to help guide 
cancer screening and risk management strategies for the enrollee. The Plan denied your request. The Plan says 
this testing has been evaluated by the MolDX Program and is considered non-covered at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that this test must satisfactory complete a TA by 
MolDX for the stated indications of the test. 
 
We looked at the file and Medicare rules. This test is listed in the Diagnostics Exchange Registry (DEX) 
database as non-covered. Based on this information, we decided that Medicare rules for coverage of Integrated 
BRACAnalysis have not been met. Therefore, we decided that the Plan does not have to pre-approve Integrated 
BRACAnalysis (81432, 81433).