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

 
We decided that the Plan does not have to pay for procedure code 88312 billed for date of service June 29, 
2023.   
You asked the Plan to pay for procedure code 88312. You say that this service was medically necessary. 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 88312 is 9. The MAI value for this code is 3. You billed 24 units of this 
code, 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 88312 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88312 billed for date of service June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
June 14, 2023. 
  You asked the Plan to pay for procedure codes 99100 and 99140. You say that the documentation should be 
reviewed, and the claim processed for payment. The Plan denied your request. The Plan says procedure code 
99100 and 99140 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 and 99140 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99100 and 99140 is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service June 
14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service March 22, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the billed code is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records provided do not 
show that 22 or more drug classes were tested.  Based on this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0483 billed for date of service 
March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) and administration (90471) provided on May 8, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that your doctor said you were due for this vaccine. 
You also say that you thought it would be covered. The Plan denied your request. The Plan says these services 
are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) (90715) and administration (90471) provided on May 8, 2023.  
 
Benefits for the vaccine services 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the life sustaining oxygen and oxygen supplies (A0422) 
provided on June 22, 2023. 
 
You asked the Plan to pay for life sustaining oxygen and oxygen supplies. You say that the claim should not 
have denied and to please review the submitted medical records and process the claim for payment. The Plan 
denied your request. The Plan says the payment for the life sustaining oxygen and oxygen (A0422) supplies is 
included in the fee for the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the life sustaining oxygen and oxygen supplies (A0422) 
provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement grafts and non-intravenous conscious 
sedation (D9248, D7953) provided on April 12, 2023, to April 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 bone 
replacement grafts and non-intravenous conscious sedation (D9248, D7953) provided on April 12, 2023, to 
April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on July 10, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that nothing was done differently from the last 
visit. You also say that nothing special was done for it to be an initial evaluation and management. The Plan 
denied your request. The Plan says  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99213) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided at the in-network 
benefit level by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you cannot afford the higher cost-sharing for 
an out-of-network provider. The Plan denied your request. The Plan says this provider is out-of-network with 
the Plan and the needed service can be performed within the Plan network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says enrollees may choose to receive care from an out-of-network provider, but the share of costs for 
covered services may be higher. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network benefit level. You may choose to utilize this out-
of-network provider at your Plans out-of-network benefit level. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy to be provided at the in-network benefit level by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve I-Factor peptide (20930). 
 
You asked the Plan to pre-approve I-Factor peptide (20930). You say that the requested I-Factor peptide 
(20930) during the approved surgery is medically necessary. The Plan denied your request. The Plan says the 
requested I-Factor peptide (20930) during the approved surgery is 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 I-Factor peptide (20930). Our reviewer 
says that the requested I-Factor peptide (20930) during the approved surgery is not medically necessary. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate that the requested allograft would be as safe or better than standard autograft procedures. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested I-Factor during the approved surgery 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 I-Factor peptide (20930) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve I-Factor peptide (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0862) and 
additional items and accessories (codes E0955, E1028 x2, E1002, E2361 x2, and E2603) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the provider in this case is not an in-network provider with the 
Plan. According to the information received on appeal, the requested service is available from an in-network 
provider. The Plan also says that the clinical information does not show an exception that would require the use 
of an OON provider. 
 
 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a group 2 standard power wheelchair (K0862) and additional items and accessories (codes E0955, E1028 x2, 
E1002, E2361 x2, and E2603) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the attendant control (E2331). 
 
You asked the Plan to pre-approve the attendant control . You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in 
addition to a beneficiary-operated drive control system, it will be denied as non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the attendant control  have not been met. Therefore, we decided that the Plan does not have to pre-
approve the attendant control (E2331).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87541, 87581, 87631, 87798, U0004, 
U0005) provided on December 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 87486, 87541, 87581, 87631, 87798, U0004, & U0005 are not supported in the 
medical record. Specifically, multiple unbundled codes were submitted for a single panel. 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 lab services (87486, 87541, 87581, 87631, 87798, U0004, 
U0005) provided on December 14, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 You asked the Plan to pre-approve Leqvio. You say that the medication is medically necessary for the enrollee. 
The Plan denied your request. The Plan says there is no contraindication or intolerance to the preferred agent 
Praluent. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Leqvio. Our reviewer says that the 
record indicates that the enrollee has hyperlipidemia and atherosclerotic cardiovascular disease. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative Praulent. The record does not indicate that the enrollee has a contraindication to 
or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. Our physician reviewer found the 
medication is 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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87541, 87581, 87631, 87798, U0004) 
provided on January 16, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 87486, 87541, 87581, 87631, 87798, & U0004 are not supported in the medical 
record. Specifically, multiple unbundled codes were billed for a single panel. 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 lab services (87486, 87541, 87581, 87631, 87798, U0004) provided on January 
16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71046 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the service was appropriate with the diagnosis 
code. The Plan denied your request. The Plan says the indication is not appropriate for the service rendered. 
 
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 71046 is radiologic examination, chest; 2 views. We find 
that CPT code 71046 is not supported in the medical record. CPT Code 71046 was billed with diagnosis code 
Z87.891, defined as a personal history of nicotine dependence. The diagnostic chest x-ray provided is not 
covered as a screening service. The records do not show that the test was ordered due to signs and symptoms of 
a specific medical problem. The diagnosis code billed is used with a low dose computed tomography scan to 
screen for lung cancer. However, this imaging service was not provided in this case.  Based on this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 71046 billed for date of service 
June 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L2 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found imaging shows canal 
retropulsion at fracture site which is a contraindication. Also, there is no trial of fracture bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR (polymerase chain reaction) panel testing 
provided August 4, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says the PCR testing is 
considered unproven and 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 looked at the file and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and not medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR (polymerase 
chain reaction) panel testing provided August 4, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair (PWC) with multiple power options 
(K0861), power tilt and recline, expandable controller with harness upgrade and electronic connection, and 
power seat elevation system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options, 
power tilt and recline, and power seat elevation system are covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee is functionally non-ambulatory 
and cannot use a cane or walker for mobility. He cannot functionally propel a manual wheelchair due to upper 
extremity weakness. He requires a power wheelchair for mobility and accomplishing daily activities. He cannot 
perform pressure relief independently due to upper extremity weakness and require a power wheelchair with 
power tilt and recline for adequate pressure relief and positioning. Power elevating leg rests are required for 
positioning of the lower extremities and lower extremity spasticity and contracture. The complexity of the 
enrollees seating and positioning needs necessitates a more complex group 3 power wheelchair base. A power 
seat elevator is needed for assistance with transfers since the enrollee can perform stand pivot transfers with 
assistance. The expandable controller with harness and electronic connection are necessary to operate the group 
3 power wheelchair base and the three power options via a joystick. These components are required to operate 
3 or more power options on a group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a Group 3 power wheelchair (PWC) with multiple power options (K0861), power tilt and recline, 
expandable controller with harness upgrade and electronic connection, and power seat elevation system.  
 
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.