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

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the upgraded electronics are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the enrollee has adequate 
upper body strength and control to manage standard power drive controls. The requested accessories are 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial for 
additional therapy visits. The Plan denied your request. The Plan says that the requested additional therapy 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that after the previously provided therapy treatments plus the just 
approved 18 additional visits, records do not support that the complexity of your condition as such that the 
skills of a professional therapist are required to achieve further improvement of your symptoms or functional 
status. Further utilization of the home exercise program would appear to be appropriate after completion of the 
additional 18 visits just approved unless additional records are received indicating further skilled 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94060, 94726, and 94729 billed for date of 
service June 21, 2022. 
 
You asked the Plan to pay for procedure codes 94060, 94726, and 94729. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says these codes are included in the facility payment and 
is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 94060, 94726, and 
94729. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 94060, 94726, 
and 94729. Based on this information, we decided that Medicare rules for coverage of procedure code 94060, 
94726, and 94729 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 94060, 94726, and 94729 billed for date of service June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure, PrismRA testing 
(81479) provided January 4, 2023. 
 
You asked the Plan to pay for the PrismRA testing. You say that PrismRA should be considered medically 
necessary for the enrollee. The Plan denied your request. The Plan says this test is not FDA approved and based 
on the diagnostic program, MolDX Technical Assessment, the requested PrismRA test is not an approved test. 
 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. Online search of the FDA list of cleared or approved companion 
diagnostic testing does not mention this PrismRA. Search of the DEX Diagnostic Exchange registry for the 
diagnostic program MolDX Technical Assessment, states that this PrismRA test is not covered. Based on this 
information, we decided that Medicare rules for coverage of the PrismRA testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the unlisted molecular pathology procedure, PrismRA testing 
(81479) provided January 4, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 17, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that this claim was timely filed. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 30, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on October 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connector (E2310). 
 
You asked the Plan to pre-approve an electronic connector. You say that this is medically necessary. 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 power option can be controlled using its own switch. 
 
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 connector. 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 adequate strength to manage standard power drive controls. 
 
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 connector have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connector (E2310).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93970 for date of service August 22, 2022. 
 
You asked the Plan to pay for procedure code 93970. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Review of the file shows lack of evidence of prior 
payment. The documentation did not include a remittance to show that one unit was paid. Based on this 
information, we decided that Medicare rules for coverage of procedure code 93970 have been met. Therefore, 
we decided that the Plan has to pay for procedure code 93970 for date of service August 22, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power 
wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says that the 
requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that you are 
functionally non-ambulatory and at high risk for falling and cannot use a cane or walker for mobility. You 
cannot functionally propel a manual wheelchair due to upper extremity weakness, lack of endurance, and 
inclusion body myositis. You cannot use a power scooter due to your lack of ability to transfer independently 
and your current living facility will not accommodate the turning radius required. You require a power 
wheelchair for mobility and accomplishing your daily activities. However, the clinical documentation is 
insufficient as to why a lower-level power wheelchair would not suffice for your mobility needs versus the 
requested power wheelchair. You do not have a history skin breakdown and do not require assistance for 
pressure relief. As the base power wheelchair is not medically necessary, the requested accessories are not 
covered.   
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array and implantable neurostimulator electrode. 
 You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array and 
implantable neurostimulator electrode. 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 SCS) may be covered for the relief of chronic 
intractable pain under certain circumstances. 
 
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 percutaneous implantation of 
neurostimulator electrode array and implantable neurostimulator electrode. Our reviewer says that the services 
are not medically necessary. Our physician reviewer found the enrollee does not have an indication as 
delineated by the LCD. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array and implantable 
neurostimulator electrode have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous implantation of neurostimulator electrode array and implantable neurostimulator electrode.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 2, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
December 2, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, and 81351.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says 8 additional 
physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. The enrollee has no recent injury or a 
decline in function. The additional therapy services are not appropriate duration and frequency for treatment of 
the enrollees medical condition and therefore are not medically 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 03, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this should not require authorization. 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 laboratory services 
provided on December 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 for date of service April 20, 2022. 
 
You asked the Plan to pay for procedure code 99222. 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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, this service was billed with 
modifier 26. Modifier 26 cannot be used with this code as billed. The claim is not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99222 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99222 for date of service April 20, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
November 3, 2022. 
 You asked the Plan to pay for procedure codes 88341 and 88342. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says payment for codes 88341 and 88342 is 
bundled into payment for code 88360. 
 
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 88341 
and 88342 is a column II code to column I code 88360. 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 codes 88341 and 88342 billed for date 
of service November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D4266), an osseous (D7950), 
and anesthesia (D9222/D9223), provided on May 23, 2022. 
 
You asked the Plan to pay for D4266, D7950, D9222, and D9223. You say that you needed this dental work. 
The Plan denied your request. The Plan says the rendered dental 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 Plans 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 pay for a guided 
tissue regeneration (D4266), an osseous (D7950), and anesthesia (D9222/D9223), provided on May 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 4, 2022. 
 
You asked the Plan to pay for the home health services. You say that this claim should be reprocessed for 
payment. 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 March 5, 2022. The NOA was not received by the Plan until June 10, 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 on April 
4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging with single-photon emission 
computed tomography (SPECT). 
 
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 enrollee has a history of 
hyperthyroidism and multiple medical conditions. The history and physical examination make no mention of 
hyperparathyroidism. There are no laboratory measurements of parathyroid hormone and calcium levels. There 
is no mention of referral to a specialist or of ordering a parathyroid scan for surgical planning purpose. The services are not medically necessary based on the submitted documentation. 
 
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 parathyroid planar imaging with single-photon emission computed tomography (SPECT).