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

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), back canes 
(K0108), armrests with elbow support (K0108), elbow supports (K0108), and push handles (K0108). 
 
You asked the Plan to pre-approve a power seat elevation system, back canes, armrests with elbow support 
when coded as K0108, elbow supports, and push handles. You say that the records provided support the need 
for the items which remain in dispute. The Plan denied your request. The Plan says power seat elevation 
systems are non-covered. The Plan says that back canes and push handles do not serve a medical purpose. The 
Plan says that the code requested for armrests with elbow support is incorrect and does not properly represent 
the description of the requested item. The Plan says that coverage for elbow supports would be included in the 
type of armrests being requested and should not be separately requested. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules say that providers must report services correctly and shall not report multiple codes 
when a single comprehensive code describes these services.  
 
The back canes and push handles at issue in this appeal do not serve a purpose that is primarily medical in 
nature. The armrests with elbow support at issue in this appeal are better represented by code E0973, and not 
by the requested K0108. Elbow supports are bundled into the requested armrests and would not be separately 
payable. Power seat elevation features are non-covered because they are not primarily medical in nature. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300), back 
canes (K0108), armrests with elbow support (K0108), elbow supports (K0108), and push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 for date of service September 15, 
2022. 
 
You asked the Plan to pay for procedure code 99239. 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 99239 is hospital discharge day management; more than 
30 minutes.  

We find that CPT code 99239 is not supported in the medical record. Specifically, the discharge summary does 
not support hospital discharge day management of more than 30 minutes was performed. A documented 
duration of 31 minutes or more is required to support this code. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99239 for date of service September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87481, 87653, 87798 and 87641 billed for date of 
service October 12, 2022. 
 
You asked the Plan to pay for codes 87481, 87653, 87798 and 87641. You say that these services were 
medically necessary and are supported in the medical record. The Plan denied your request. The Plan says the 
payment for these services is included in the payment for other services provided on this same date. 
 
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 codes 87481, 87653, 87798 and 87641 are column II codes to column I 
code 87801; however, codes 87798 and 87641 were billed with a modifier. Codes 87481 and 87653 were not 
billed with a modifier, so they are excluded from payment based on bundling rules. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for codes 87481, 87653, 87798 and 87641. Our reviewer says 
that codes 87481, 87653, 87798 and 87641 are not separately payable. Our reviewer found the enrollee is a 92-
yr old female that received multiple laboratory procedures on October 12, 2022. You reported the following 
procedures with modifier XU Unusual Non-Overlapping Service, and billed with culture typing and infectious 
agent detection multiple organisms; amplified probe technique:  
 
Current Procedural Terminology (CPT) 87798 Infectious agent detection by nucleic acid (DNA or RNA), not 
otherwise specified; amplified probe technique, each organism 
 
Current Procedural Terminology (CPT) 87641 - Legionella pneuophila, amplified probe technique 
 
For CPT 87798, the documentation submitted was reviewed, and does not meet criteria for separate payment. 
Although, modifier XU was appended to procedure code CPT 87798, the laboratory report does not include 
documentation of how this procedure unusual non-overlapping service from column 1 codes, and therefore 
modifier cannot be verified. 
 
For CPT 87641, the documentation submitted was reviewed, and does not meet criteria.  An NCCI edit exists 
between column II codes 87798 and 87641 and both column I codes 87801 and 87150. Modifiers are allowed 
to bypass each of these edits.  Although, modifier XU was appended to procedure code CPT 87641, the 
laboratory report does not include documentation of how this procedure unusual non-overlapping service from 
column 1 codes, and therefore modifier cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87481, 87653, 87798 and 87641 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 87481, 87653, 87798 and 87641 billed for date of service 
October 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted procedures, esophagus, x 2 (43499 x 2). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has a Zenker's diverticulum. There is insufficient literature 
to support the safety and efficacy, as defined by Medicare rules, of the requested service for the enrollee's clinical condition. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the unlisted procedures, esophagus, x 2 (43499 x 2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from April 29, 2023, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 there were no skilled nursing needs. As of last covered day, the enrollee did not 
require any skilled nursing or rehabilitation services on a daily basis. The enrollee was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or self-care tasks. The enrollee did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an 
inpatient basis, at a skilled level of care as of April 28, 2023. 
 
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 the continuation of skilled nursing facility (SNF) care from April 29, 2023, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve the acute inpatient hospital level of care. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the surgery is approved but the inpatient level of care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient care are met. Our physician reviewer 
found the enrollee has been approved for a left shoulder arthroplasty. The planned procedure is not on the 
inpatient-only list. The enrollee is medically stable and has been provided medical clearance for the procedure. 
There is no documentation to support that the enrollee will require at least two midnights of inpatient hospital 
care for the approved procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve the acute inpatient hospital level of care.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the dental services described by code D0999 provided on 
December 8, 2022. 
 
You asked the Plan to hold you harmless for the services coded D0999. You say that you feel that these 
services should be covered because of the issues you had getting your records from the previous network 
provider. The Plan denied your request. The Plan says that it was determined to approve the exam and x-rays 
due to the issue you had. However, code D0999 is not covered by your dental benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided with the services coded D0999 by a contract provider. The file does not show what this 
code is used to represent. There is also nothing in the file indicating that you were informed that this charge 
would be noncovered. As such, we find that this service is considered to be approved by the Plan. Therefore, 
we decided that the Plan has to hold you harmless for the dental services described by code D0999 provided on 
December 8, 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 the electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), attendant control (E2331), an 
expandable controller (E2377), an active reach package, toggle switches on switchbox and an extra link for 
headrest hardware (K0108 x 3). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the upgraded electronics (expandable controller, harness and electronic connector 
to 2 power options) are not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer 
found the requested electrical accessories are not medically necessary as you do have use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), a harness (E2313), attendant control (E2331), an expandable controller (E2377), an active 
reach package, toggle switches on switchbox and an extra link for headrest hardware (K0108 x 3).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 81272 on date of service 
September 15, 2022. 
 
You asked the Plan to pay for code 81272. You say that you have provided medical records to support payment 
of this code. The Plan denied your request. The Plan says there is a more appropriate code for the services 
provided. 
 
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 81272 is  KIT (v-kit Hardy-Zuckerman 4 feline sarcoma 
viral oncogene homolog) (e.g., gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), 
gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 17, 18). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 81272. Our reviewer says that code 81272 is not 
supported by the medical records. Our reviewer found the laboratory report does not include documentation of 
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., gastrointestinal stromal tumor 
[GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 
17, 18).  The laboratory report describes a comprehensive complete cancer panel - 82 genes have been 
performed.  In this case, CPT 81272 cannot be verified, as this procedure was not found in laboratory report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 81272 have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services billed with code 81272 on date of service September 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty (22514). You say that the requested L1 kyphoplasty 
(22514) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for L1 kyphoplasty (22514). 
 
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 L1 kyphoplasty (22514). Our reviewer 
says that the enrollee does not meet criteria for L1 kyphoplasty (22514). Our physician reviewer found based 
on the documented history the enrollee has been having back pain for more than 3 months. There is no 
evidence of an acute fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty (22514) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L1 kyphoplasty (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth #6. 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for D6740 will be exhausted with the approval of D6740 for tooth #5. Therefore, we 
decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth #6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder. 
 
You asked the Plan to pre-approve a cup holder. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is a convenience item and not primarily medical in nature. 
 
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 cup holder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires (A4557) and the standby service (99360) 
provided on October 13, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. For code 99360, standby services are not 
payable to physicians. Physicians may not bill Medicare or beneficiaries for standby services. Payment for 
standby services is included in the Part A payment to the facility. Such services are a part of hospital costs to 
provide quality care. If hospitals pay physicians for standby services, such services are part of hospital costs to 
provide quality care. Furthermore, records indicate that code A4557, has a status indicator of 'P' on the CMS 
Physician Relative Value File, is always bundled into payment for other services not specified and no separate 
payment is made per Medicare. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lead wires 
(A4557) and the standby service (99360) provided on October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says upgraded electronics cannot be covered. They are necessary when there is a 
medical need to control power options though the joystick. The notes do not show a medical need to control the 
power options through the joystick. The power options can be controlled using their own switches. 
 
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. Although two 
power features are requested for this wheelchair (tilt and elevating leg rests), there is not a medical need to 
control these power options through the joystick. The records show that the enrollee's upper limb strength is 
adequate for the enrollee to control using their own switches which are included in the allowance of the power 
options. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311).