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

 
We decided that the Plan does not have to pay for procedure code 87900 billed for date of service January 13, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the code. 
 
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 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. We find that CPT code 87900 is not supported in the medical record. The results of susceptibility testing are 
interpreted as S (sensitive), I (intermediate), or R (resistant) followed by the minimum inhibitory concentration 
(MIC) in microgram per milliliter (ug/mL) units. In this case, the MIC has not been reported in the 
documentation submitted. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87900 
billed for date of service January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82040, 82306, 82310, 82374, 82435, 82565, 
82728, 83540, 84075, 84100, 84132, 84155, 84295, 84450, 84460, 86706, 87340, A4657, and J1270 related to 
end-stage renal disease (ESRD) provided on December 2, 2022, to December 30, 2022. 
 
You asked the Plan to pay for the ESRD-related services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related services. 
 
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. Additionally, codes A4657 and 
J1270 are listed as not separately payable when related to ESRD services. Therefore, we decided that the Plan 
does not have to pay for procedure codes 82040, 82306, 82310, 82374, 82435, 82565, 82728, 83540, 84075, 
84100, 84132, 84155, 84295, 84450, 84460, 86706, 87340, A4657, and J1270 related to end-stage renal 
disease (ESRD) provided on December 2, 2022, to December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 11, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced foot (L5981, L5986) for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve an advanced foot. You say that the request is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that the requested advanced foot is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a lower limb prosthesis is covered when the 
beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
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 advanced foot. Our reviewer says 
that the requested advanced foot is medically reasonable and necessary in this case. Our physician reviewer 
found that the rules state simply that ...flex foot system (L5981)... is covered for beneficiaries whose 
functional level is 3 or above. No further specific documentation is actually required in the rules; Medicares 
policy recognizes that flex-walk feet (and their routine additions such as L5986) are part of the basic standard 
of care for all community K3 amputee ambulators, given that the evidence of their benefits and superiority to 
less sophisticated alternatives are so well proven and long-standing. Beyond that, even if the enrollee were not 
a K3 ambulator, the rules are specifically lenient in coverage criteria for bilateral amputees, which the enrollee 
is. There is no doubt whatsoever that original Medicare would cover the requested prosthesis 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 an advanced foot have been met. Therefore, we decided that the Plan has to pre-
approve an advanced foot (L5981, L5986) for a lower-limb prosthesis.   
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not able to go home alone, and family 
want the admission the inpatient rehabilitation. The Plan denied your request. The Plan says the records do not 
meet Medicare guidelines because the enrollee is currently receiving adequate and necessary intensive 
rehabilitation in the Inpatient Rehabilitation Facility.  
 
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 pre-approve 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 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 and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pre-approve skilled nursing facility (SNF) care.
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 Inpatient Rehabilitation Facility admission for the 
enrollee's cognitive deficits, generalized weakness, and mild balance deficits. The Plan denied your request. 
The Plan says the enrollee does not have complex rehabilitation needs. The Plan says that the services needed 
may be provided safely in a lower 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 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.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an implant supported to crown (D6065) for tooth #19 and #30. 
 
You asked the Plan to pre-approve the dental services. You say that you already had the work of the screws for 
the crowns completed and the requested dental services are necessary. The Plan denied your request. The Plan 
says that the denial of authorization for the implant supported to crown is correct, because there is no evidence 
that supports this type of service. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the implant supported to crown for tooth #19 and #30 is medically reasonable and necessary. Our 
physician reviewer found that the periapical x-rays were included for implants in teeth #19 and #30 areas. Per 
the EOC section 2.1 states that implant supported porcelain crown (ceramic) are cover 2 per year. Based on the 
information included, it is unknown whether this enrollee has had any previous implant crowns placed in 2023. 
Code D6068 is not an appropriate code to use in this situation, this code is for a crown that is a part of a bridge. 
The enrollee has 2 single implants on opposite sides of the mouth. What is required is a single crown placement 
on each of the placed implants. Code D6065, which the dental provider requested is an appropriate code in the 
treatment for this enrollee. Code D6065 is medically reasonable and necessary for this enrollee as the implant 
crowns will help aid in restoring the enrollee's ability to chew his food in these areas. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve an implant supported to crown (D6065) for tooth #19 and #30.  
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this service is medically necessary. You 
say that this falls under the definition of appropriate standard of care. You also say that this is a covered benefit 
under the enrollee's insurance. The Plan denied your request. The Plan says this is considered experimental and 
therefore is not covered. 
 
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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental for use in the spine. Therefore, the reviewer 
found that the Vertilfex device is not medically reasonable or 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241) provided on April 3, 2023. 
 
You asked the Plan to pay for the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant.. 
You say that this testing is medically necessary. The Plan denied your request. The Plan says this testing is not 
covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant. have not been met. 
Therefore, we decided that the Plan does not have to pay for the F2 (prothrombin, coagulation factor II) (eg, 
hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241) provided on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair component or accessory, not otherwise 
specified, a transit system (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that an optimally configured push 
wheelchair as mobility device is medically necessary to improve the enrollee's ability to safely complete 
activities of daily living and other activities in her home setting. The Plan denied your request. The Plan says 
the transit system does not serve a primary medical purpose; it is statutorily non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does 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 a wheelchair component or accessory, not otherwise 
specified, a transit system (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99233 
performed on May 3, 2023, and 99233 performed on May 4, 2023. 
 
You asked the Plan to pay for the evaluation and management services. You say that 99233 billed on May 3, 
2023, and 99233 billed on May 4, 2023, should be covered because they are supported in the documentation. 
The Plan denied your request. The Plan says 99233 billed on May 3, 2023, and 99233 on May 4, 2023, are 
denied because they are not supported in the documentation. 
 
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 99233 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 high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
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 evaluation and management services. 
Our physician reviewer says that 99233 billed on May 3, 2023, and 99233 billed on May 4, 2023, are not 
sufficiently supported in the record. Our reviewer found the documentation from May 3, 2023, described the 
enrollee with chronic back pain but resting comfortably with pain controlled from the pain pump, with stable 
vitals. No change in treatment was recommended. The documentation from May 4, 2023, described the 
enrollee with low back pain but resting comfortably, and an appropriate exam. However, the documentation 
again described the enrollee as medically stable, with stable pain pump, and without a need for treatment 
change. The documentation did not reveal a high level of decision making for either May 3, 2023, or May 4, 
2023, nor were there details in the documentation describing the encounters each lasting at least 50 minutes.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the evaluation and management services have not been met. Therefore, we 
decided that the Plan does not have to pay for the evaluation and management services coded as 99233 
performed on May 3, 2023, and 99233 performed on May 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 29, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that this service was billed appropriately and is 
separately payable. 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 II code to column I code 81455 with a modifier indicator of 0. The column II 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 March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 30, 
2023.  
 
You asked the Plan to pay for procedure code 81456. 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 II code to column I code 81455 with a modifier indicator of 0. The column II 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 January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom oral dental appliance. 
 
You asked the Plan to pre-approve custom oral dental appliance. 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 oral appliances are only covered for certain 
indications. 
 
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 custom oral dental appliance. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found the enrollee has mild to moderate obstructive sleep apnea. The 
documentation shows that the physician states that continuous positive airway pressure (CPAP) was not 
appropriate for the enrollee as the enrollee has dementia. However, a CPAP trial was not documented as having 
been recommended or attempted for this enrollee. Also, for the same reasons the treating physician was 
hesitant to prescribe CPAP, the enrollee's dementia might lead to a similar issue with compliance with the oral 
appliance. Therefore, without sufficient support and LCD criteria not met, the oral dental appliance will be 
considered 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 custom oral dental appliance have not been met. Therefore, we decided that the 
Plan does not have to pre-approve custom oral dental appliance.