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

 
We decided that the Plan does not have to pay for codes G0483 and 80307 for date of service May 24, 2023. 
 
You asked the Plan to pay for codes G0483 and 80307. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
The CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug classes, any 
number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, 
ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with 
or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, 
TOF) includes sample validation when performed, per date of service. 
 
We find that CPT code G0483 and 80307 is not supported in the medical record. Specifically, the medical 
records do not include laboratory results for the services billed. Based on this information, we decided that 
Medicare rules for coverage of codes G0483 and 80307 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes G0483 and 80307 for date of service May 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your needs can be met in an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service August 14, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81456 billed for date of service August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neuromonitoring billed for date of service 
June 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services are separately payable. The Plan 
denied your request. The Plan says the charges are included in the facility payment. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary.  The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made with outside providers. This service was provided via arrangement of the facility. Payment for this 
service would have been included under the facility claim. Payment to you for this service is the responsibility 
of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring billed for date 
of service June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service July 6, 2023, 
and July 7, 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 number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code for each date of service, exceeding the MUE. You did not provide all the required evidence showing that 
the excess units were actually provided, were correctly coded, and were medically necessary. 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 billed for date of service 
July 6, 2023, and July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided January 
3, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting this claim be 
reprocessed correct for payment. The Plan denied your request. The Plan says this service is not covered for 
this provider type/specialty. 
 
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 (E0676) provided January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air immersion therapy mattress. 
 
You asked the Plan to pre-approve air immersion therapy mattress. You say that this will significantly improve 
the enrollee's quality of life and health. The Plan denied your request. The Plan says there are insufficient 
studies showing a benefit from this type of mattress over one that uses air-fluid therapy. 
 
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 air immersion therapy mattress. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee already has a medical air fluid mattress and it is unclear that 
there is added benefit of an air immersion mattress. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air immersion therapy mattress have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an air immersion therapy mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporary replacement for patient owned equipment 
(wheelchair) being repaired (K0462) for 2 additional months. 
 
You asked the Plan to pre-approve a temporary wheelchair replacement for two (2) additional months. You say 
that your wheelchair was stolen, and you need a wheelchair to complete your activities of daily living. You also 
say that you were going to see your physical therapist to be assessed for the need for the wheelchair. The Plan 
denied your request. The Plan says the criteria require that only one month of a power wheelchair rental can be 
covered. The Plan also says since the criteria are not met, the request for a 3-month wheelchair rental is not 
medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that one month's rental of a power wheelchair (PWC) 
or power operated vehicle (POV) (K0462) is covered if a beneficiary-owned wheelchair is being repaired. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the Plan has already approved a 
temporary wheelchair replacement for you for one month. Based on this information, we decided that Medicare 
rules for coverage of a temporary wheelchair replacement for two (2) additional months have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a temporary replacement for patient owned 
equipment (wheelchair) being repaired (K0462) for 2 additional months.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the handbrakes (A9270) and basket upgrade (A9270). 
 
You asked the Plan to pre-approve the handbrakes and basket upgrade. You say that you feel that you need the 
brakes to prevent the walker from rolling out from under you when you go to sit down. Please reconsider the 
decision. The Plan denied your request. The Plan says these items are 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 handbrakes and basket upgrade have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the handbrakes (A9270) and basket upgrade (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided by a 
chiropractor on July 10, 2023, to August 21, 2023. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that your goal is to not pay for 
the maintenance visits. The Plan denied your request. The Plan says ongoing maintenance therapy is not 
considered to be medically necessary under the Medicare program.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care. 
 
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 chiropractic manipulative treatment. Our 
reviewer says that the chiropractic manipulative treatment is not medically necessary. Our physician reviewer 
found that you have cervical and lumbar segmental dysfunction following an injury in January of 2023. The 
records indicate that you have reached maximum improvement for the noted condition and that further 
treatment is maintenance therapy. However, the records provided does not establish the medial necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the elements of the coverage 
criteria are not satisfied, and the requested service is not recommended. 
 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 chiropractic manipulative treatment have not been met. Therefore, we 
decided that the Plan does not have to pay for the chiropractic manipulative treatment provided by a 
chiropractor on July 10, 2023, to August 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can barely stand on their own and can 
barely walk. The enrollee does not have anyone who can assist them at home. The Plan denied your request. 
The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test and a specialist 
office visit provided on April 17, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test and a specialist office visit. 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 $20 
copayment for outpatient diagnostic test /Medicare-covered non-radiological diagnostic services and a $35 
copayment for physician/practitioner services/specialist.  You have been asked to pay a $20 copayment for an outpatient diagnostic test and a $35 copayment for a 
specialist office visit. However, since the allowed amount is less than the standard copayment for the 
diagnostic test, you only owe $11.11. The total amount you are being asked to pay is $46.11 ($35 + $11.11= 
$46.11 This item/service falls within the outpatient diagnostic test /Medicare-covered non-radiological 
diagnostic services and physician/practitioner services/specialist 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 test and a specialist office visit provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of erupted tooth (D7210), add tooth to 
existing partial denture (D5650), and adding a clasp to an existing partial denture (D5660) provided on October 
24, 2022. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
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 surgical 
removal of erupted tooth (D7210), add tooth to existing partial denture (D5650), and adding a clasp to an existing partial denture (D5660) provided on October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve addition, endoskeletal system, below knee, flexible protective outer surface 
covering system. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection. 
 
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 addition, endoskeletal system, below 
knee, flexible protective outer surface covering system. Our reviewer says that the documentation does not 
support that the requested addition is medically reasonable or necessary. Our physician reviewer found the 
enrollee is cleared for prosthesis. The enrollee's expected level of activity is K2. The documentation does not 
reveal that the enrollee has special needs for protection against unusually harsh environmental situations where 
it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by a standard 
prosthetic cover. Therefore, the enrollee does not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of addition, endoskeletal system, below knee, flexible protective outer surface 
covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, 
endoskeletal system, below knee, flexible protective outer surface covering system (L5962).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on the enrollee's condition the current care 
team has determined that the enrollee meets the criteria for an IRF admission. The Plan denied your request. 
The Plan says the enrollee's medical and therapy needs could be met in a skilled nursing unit.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.