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

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. We also decided the Plan does not have to pre-
approve a hook, a backpack holder, a foot plate and a calf panel. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection and a hook, 
a backpack holder, a foot plate and a calf panel. You say that the requested items are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested items 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. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee has sufficient strength and function 
in upper extremities to manage standard power drives. 
 
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 expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair.  
 
A hook, a backpack holder, a foot plate and a calf panel do not serve a purpose that is primarily medical in 
nature. Therefore, we decided that the Plan does not have to pre-approve a hook, a backpack holder, a foot 
plate and a calf panel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service February 2, 
2023. 
 
You asked the Plan to pay for procedure code 87798. You say that this service is supported as billed. The Plan 
denied your request. The Plan says this code is not supported for separate reporting or payment. 
 
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 87798 is a column II code to column I code 87801; however, 87798 
was billed with a modifier.  
 
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 procedure code 87798. Our reviewer says that code 87798 is 
not supported with modifier XU. Our reviewer found the laboratory report does not include documentation to 
support that this was an unusual non-overlapping service. In this case, these two codes should not be reported 
in combination of one another. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87798 billed for date of service February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (36200) provided on February 16, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was not 
billed with the appropriate modifier. 
 
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 payment for CPT code 36200 is not supported in the medical record. Specifically, the records 
show that the procedure was rendered on the left side, and the claim was billed with a left-sided diagnosis code. 
However, code 36200 was not billed with the -LT modifier required in this case. 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 services (36200) provided on February 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97112, and 97530 provided on May 
1, 2023. 
 
You asked the Plan to pay for procedure codes 97110, 97112, and 97530. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support 
the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97110 is Therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The 
definition of code 97112 is Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular 
reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. The definition of code 97530 is Therapeutic activities, direct (one-on-one) patient 
contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT codes 97110, 97112, and 97530 are not supported in the medical record. Specifically, the 
records do not document how many minutes were spent providing each activity to verity the number of units 
for the codes billed. Based on this information, we decided that Medicare rules for coverage of procedure codes 
97110, 97112, and 97530 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 97110, 97112, and 97530 provided on May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve these items an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), a harness (E2313) and an 
expandable controller (E2377).  
 
You asked the Plan to pre-approve these items wheelchair accessories. You say that the physical therapy 
evaluation documents that the enrollee cannot functionally weight shift on her own. This would place the 
enrollee at a heightened risk of morbidity and or mortality if she cannot offload her pelvis throughout the day to 
prevent skin injury. The Plan denied your request. The Plan says the upgraded electronics 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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that a group 3 power wheelchair can be covered if the medical necessity for a PWC is 
met and if the disorder causing the mobility limitation is a neurological condition, myopathy or congenital 
skeletal deformity. The enrollee also must require a drive control interface, power tilt or a power recline seating 
system and if there has been a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a physical or occupational therapist. An expandable controller is an electronic system that 
is capable of accommodating one or more additional features and can operate 3 or more powered seating 
options. The requested electrical accessories are not medically necessary as the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. There is not a medical need for the upgraded electronics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve these items an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 96368 and 96375. We decided that the Plan does not 
have to pay for procedure code 99214.  
 
You asked the Plan to pay for procedure codes 99214, 96368, and 96375 billed for date of service August 16, 
2022. You say that you do not agree with the determination. The Plan says that the billed codes are not 
supported. 
 
We decided that the Plan has to pay for procedure codes 96368 and 96375.  
 
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 96368 and 96375 are an add-on codes. These codes have been billed 
with an appropriate primary procedure code, 96365, which the Plan has agreed to pay for. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan has to pay for 
procedure codes 96368 and 96375 billed for date of service August 16, 2022. 
 
We also decided that the Plan does not have to pay for procedure code 99214. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. CPT code 99214 was billed with modifier 25. The records do not show that 
this evaluation and management service was separate and identifiable from the other services performed on this 
date of service. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99214 billed for date of service 
August 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87471, 87481, 87500, 87640, 87641, 87653 
and 87798 billed for April 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87471, 87481, 87500, 87640, 87641, 87653 and 87798 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 87471 is infectious agent detection by nucleic acid (DNA 
or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique. The definition of code 
87481 is infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella 
quintana, amplified probe technique. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique. The definition of 
code 87640 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified 
probe technique. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87653 is 
infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. 
 
We find that CPT codes 87471, 87481, 87500, 87640, 87641, 87653 and 87798 are not supported in the 
medical record. Specifically, each billed code represents on component of a multi-component code and a more 
specific single code should be billed. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87471, 87481, 87500, 87640, 87641, 87653 and 87798 billed for April 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 15, 
2022, to December 16, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission and care were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says inpatient admission and care 
were 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that there was no documentation provided indicating medical necessity for inpatient 
hospital services. The enrollee did not require surgery or inpatient treatment requirements. No cardiac issues 
were found. The record did not show that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
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 pay for the acute inpatient hospital care provided from December 15, 2022, to December 
16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q9966 billed for March 22, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code Q9966 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 Q9966 is low osmolar contrast material, 200-299 mg/ml 
iodine concentration, per ml. 
 
We find that CPT code Q9966 is not supported in the medical record. Specifically, the units billed do not 
correspond with the smallest dose available for purchase that can provide the appropriate dose for the patient. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code Q9966 billed for March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76700, 93976, and 93979 billed for date of 
service May 3, 2023. 
 
You asked the Plan to pay for procedure codes 76700, 93976, and 93979. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 76700 and 93979 is bundled into 
payment for code 93976. Code 93976 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. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. In this 
case, we have confirmed that codes 76700 and 93979 are column II codes to column I code 93976. While these 
codes were billed with the -59 modifier, the medical records provided do not show that the services billed with 
the -59 modifier is a distinct procedural service.  
 
We find that CPT code 93976 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of duplex scan of arterial inflow and venous outflow of abdominal, pelvic, 
scrotal contents and/or retroperitoneal organs; limited study; therefore, code 93976 is not supported. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 76700, 93976, and 93979 billed for date of service May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service November 
15, 2022.  
 
You asked the Plan to pay for procedure code 99233. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99233 is bundled into payment for code 01844. 
 
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 99233 
is a column II code to column I code 01844 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 99233 billed for date of service November 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is necessary due to the enrollee's 
increasing dependency on others and their very high risk for falls, injury, and re-hospitalization. You would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says admission to 
an IRF is not medically necessary.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion. 
 
You asked the Plan to pre-approve lumbar spinal fusion. You say that the records provided support the need for 
the requested surgery. The Plan denied your request. The Plan says multilevel fusion is considered 
experimental, investigational, and unproven. The Plan says that the medical necessity criteria have not been 
met. 
 
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 lumbar spinal fusion. Our reviewer says 
that lumbar spinal fusion services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found records show the enrollee is a current smoker. Smoking is a contraindication to 
fusion. Also, multilevel fusion for back pain without instability is not likely to be successful.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar spinal fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar spinal fusion.