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

 
We decided that the Plan does not have to pay for procedure code 73070-26-LT billed for date of service 
November 11, 2022. 
 You asked the Plan to pay for procedure code 73070-26-LT. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 73070-26-LT is bundled into 
payment for code 73080. 
 
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 
73070-26-LT is a column II code to column I code 73080. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 73070-26-LT billed for date of 
service November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided July 22, 
2022, to August 22, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you have outlined in this appeal, 
how this enrollee's medical necessity actually meets the guidelines that qualify for coverage. The Plan denied 
your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided July 22, 2022, to August 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto (J8499). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto (J8499).   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 for date of service January 26, 2023. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are 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 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
 
 We find that CPT code 99232 is not supported in the medical record. Specifically, this code was billed with 
diagnosis codes Ell.621(Type 2 diabetes mellitus with foot ulcer) and E08.621 (Diabetes mellitus due to 
underlying condition with foot ulcer}. These two diagnosis codes should not be billed together. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99232 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99232 for date of service January 
26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF test provided on December 25, 2022. 
 
You asked the Plan to pay for the Tempus xF test. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare nationally covers FDA-approved NGS testing, when the test is 
FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF test have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF test provided on 
December 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 You asked the Plan to pre-approve kyphoplasty. 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 PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation of a trial of 
bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral sacroiliac joint fusion, represented by codes 
69990 and 27280. 
 
You asked the Plan to pre-approve bilateral sacroiliac joint fusion. You say that you need this surgery because 
you have been dealing with pain for a long time. The Plan denied your request. The Plan says the requested 
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 bilateral 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 you have diagnoses of lumbar spondylosis without myelopathy, lumbar 
radiculopathy, lumbar degenerative joint disease, chronic pain, and bilateral sacroiliitis complaining of bilateral sacroiliac (SI) joint pain. There is no SI joint instability, fracture, or lesion. Si joint fusion for degenerative 
back pain is experimental. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral sacroiliac joint fusion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bilateral sacroiliac joint fusion, represented by codes 69990 and 27280.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on January 20, 2023, billed 
with code 99232. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital care provided have not been met. This claim was billed with diagnosis codes 
E11.621 and E08.621 which is a code pair that is subject to an Excludes1 note and can never be billed together. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on January 20, 
2023, billed with code 99232.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry, interpretation; 16 or more markers provided 
on August 2, 2022. 
 
You asked the Plan to pay for flow cytometry, interpretation; 16 or more markers. The Plan denied your 
request. The Plan says code 88189-Flow cytometry, interpretation; 9 to 15 markers is not a Medicare benefit 
for the diagnoses listed on the claim and are done for screening purposes. 
 The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file does not show a covered diagnosis per the Medicare LCD 
coverage criteria. Based on this information, we decided that Medicare rules for coverage of flow cytometry, 
interpretation; 16 or more markers have not been met. Therefore, we decided that the Plan does not have to pay 
for flow cytometry, interpretation; 16 or more markers provided on August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve palliative care. 
 
You asked the Plan to pre-approve palliative care. You say that palliative care is medically necessary due to 
your pain as a result of your rare MPN blood cancer. The Plan denied your request. The Plan says the patient 
does not have a life limiting illness with prognosis measures in at least 1-2 years. Her symptoms arise from a 
chronic condition and should be treated by chronic pain and her outside pain specialist. She should also 
undergo treatment recommended by Ob/Gyn. Review of the chart shows that she does not have vulvar cancer. 
The most recent biopsy is VIN 3, which is vulvar dysplasia. 
 
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 palliative care. Our reviewer says that 
the requested palliative care is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided there is no documentation that the requested 
palliative care at issue in this case meets all Medicare criteria for medically reasonable and necessary. The 
provided records in this case do not document that you have advanced cancer or a serious life-threatening 
diagnosis with a poor prognosis for which palliative care would generally be medically reasonable and 
necessary. The provided records document that you have reasonable treatment options available to improve 
your pain and disability before the need for palliative 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 palliative care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve palliative care.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and infusion 
supplies not used with external infusion pump, per cassette or bag (list drugs separately) (A4223) provided 
October 26, 2022, to October 31, 2022. 
 You asked the Plan to pay for the home IV infusion supplies. You say that you provided the IV infusion 
therapy for the enrollee at home and the home IV infusion supplies was omitted from reimbursement. The Plan 
denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the disposable drug delivery system (A4305) and infusion supplies not used with external infusion pump, 
per cassette or bag (list drugs separately) (A4223) provided October 26, 2022, to October 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 31, 2022, to 
March 1, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 1, 2022. The NOA was not received by the Plan until September 
21, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 31, 2022, to March 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Hyaluronan or derivative, Hyalgan, Supartz or visco-3, for 
intra-articular injection (J7321) provided on November 16, 2022. 
 
You asked the Plan to pay for the Hyaluronan or derivative, Hyalgan, Supartz or visco-3, for intra-articular 
injection. You say that the injection was medically necessary. The Plan denied your request. The Plan says the 
clinical value and effectiveness of Supartz in the setting of hip osteoarthritis have not been demonstrated in the 
peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Hyaluronan or derivative, Hyalgan, 
Supartz or visco-3, for intra-articular injection. Our reviewer says that the requested Hyaluronan or derivative, Hyalgan, Supartz or visco-3, for intra-articular injection is not considered medically necessary. Our physician 
reviewer found that the literature states that viscosupplementation therapy is medically necessary for the 
treatment of osteoarthritis in the knee. It is considered experimental and investigational for indications such as 
chondromalacia patellae, facet joint arthropathy, following anterior cruciate ligament reconstruction, 
meniscectomy, or partial or total knee arthroplasty; hemophilic arthropathy, muscle stiffness, spastic 
hemiparesis, osteochondritis dissecans, palendromic rheumatism, patellofemoral arthritis, patellofemoral 
syndrome (patellar knee pain), peripheral nerve pain, plantar nerve entrapment syndrome, psoriatic arthritis, or 
for use in joints other than the knee (e.g., ankle, carpo-metacarpal joint, elbow, hip, metatarso-phalangeal joint, 
shoulder, thumb, and temporomandibular joint) because the effectiveness of viscosupplementation for these 
indications has not been established. The review has determined that the documentation does not support that 
Supartz is medically reasonable or necessary for the enrollee. The documentation does not support that the drug 
Supartz is safe and effective for the enrollee. 
 
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 Hyaluronan or derivative, Hyalgan, Supartz or visco-3, for intra-articular 
injection have not been met. Therefore, we decided that the Plan does not have to pay for a Hyaluronan or 
derivative, Hyalgan, Supartz or visco-3, for intra-articular injection (J7321) provided on November 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 13, 2022, to 
August 11, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this claim has been billed 
correctly and should be paid. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 13, 2022, to August 
11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on May 19, 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 Current Procedural Terminology (CPT) 99285 remains 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 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation listed a 
comprehensive examination but the history was focused and brief. Based on the low severity and low 
complexity presentation of this enrollee, there was insufficient support in the documentation for medical 
decision-making of high complexity, nor was there evidence of a life-threatening condition.  
 
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 emergency department services (procedure code 99285) rendered on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laparoscopic radical prostatectomy (55866) 
non-covered item or service (A9270) provided October 12, 2022, to October 13, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery . You say that you were told that the 
facility where the outpatient procedure would be performed at was in-network 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 50% 
coinsurance for each Medicare-covered outpatient surgery at an ambulatory surgical center or outpatient 
hospital facility.  
 You have been asked to pay $6,248.44 (12,452.87 x 50% = $6,226.43 + $22.01) for the outpatient surgery. 
This item/service falls within the Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 laparoscopic radical prostatectomy (55866) non-covered item or service (A9270) provided October 12, 
2022, to October 13, 2022.