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

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377, E2394, K0108). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the accessories. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records were completely re-reviewed on 11/20/2023. The records document 
that the enrollee has 3/5 right upper extremity strength with no reported limitations and the patient is 
independent with feeding, grooming, dressing and meal preparation, thus indicating he has adequate upper 
extremity strength and function to operate the wheelchairs power options with their own switches. The records 
do not support that the components (E2311, E2313, E2377) are needed to control the power wheelchairs 
functions through a joystick. Components (E2394, K0108) wheel assemblies, thigh/knee/calf/arm pads and foot 
plate connector do not meet coverage criteria as they are included with the power wheelchair already approved 
and medical records from the treating physician do not document necessity of these components in addition to 
the power wheelchair and accessories already approved. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, E2394, K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
February 23, 2023, and billed with codes 87481, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on February 23, 2023, and billed with codes 87481, 87798, and 87801.
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 June 5, 2023. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided for review. 
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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D6106) provided on August 4, 
2023. 
 
You asked the Plan to pay for D6106. You say that this is the only work you have had done this year. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 a guided 
tissue regeneration (D6106) provided on August 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant removal (20680) provided on May 8, 2023. 
 
You asked the Plan to pay for the implant removal (20680). You say that the attached medical records support 
procedure code 20680 as payable. The Plan denied your request. The Plan says the removal of an internal 
fixation device is not separately reportable if the removal is performed as a necessary integral component of 
another procedure. 
 
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 20680 is removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate). 
 
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 the implant removal (20680). Our reviewer says that the 
service does not meet the criteria for coverage. Our reviewer found that the procedure report describes a 
removal of a deep implant and fixation. In this case, the procedure code and modifier are not supported as the 
procedures were performed in the same anatomical area. Therefore, the implant removal would be inclusive to 
the primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the implant removal (20680) have not been met. Therefore, we decided that the 
Plan does not have to pay for the implant removal (20680) provided on May 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284 billed for date of service July 15, 2023. 
 
You asked the Plan to pay for code 99284. You say that code 99284 was billed correctly. The Plan denied your 
request. The Plan says code 99284 is not supported by the medical record. As a result, this claim was paid at 
the 99283 level. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. 
 
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 99284. Our reviewer says that code 99284 is not supported by the medical record. Our reviewer found the enrollee is a 86-year-old woman who presented with 
hip pain.  In this case, the medical documentation does not support a detailed exam, a detailed history or 
medical decision making of moderate complexity. 
 
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 99284 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99284 billed for date of service July 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc or Supartz FX is required before alternatives can be considered. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found that the record does not indicate the enrollee is on insulin nor do they have w history of problematic 
hypoglycemia.  
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pacemaker insertion and intracardiac catheter ablation. 
 
You asked the Plan to pre-approve pacemaker insertion and intracardiac catheter ablation.. You say that the 
enrollee will suffer ongoing atrial fibrillation and could have heart failure. The Plan denied your request. The 
Plan says records show the enrollee does not have documented non-reversible symptomatic bradycardia due to 
sinus node dysfunction or second or third degree atrioventricular block.  
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 pacemaker insertion and intracardiac 
catheter ablation. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found while it does appear that the enrollees atrial 
fibrillation is likely to be chronic, the enrollee has not exhibited symptomatic bradycardia for which a 
pacemaker would be mandated. Attempts at medical management in controlling the ventricular rate do not 
appear to have been maximized according to the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pacemaker insertion and intracardiac catheter ablation. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve pacemaker insertion and intracardiac catheter 
ablation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray services described by codes R0070, 
Q0092, 73090-TC, 73120-TC, and 73100-TC billed on March 13, 2023. 
 
You asked the Plan to pay for the portable x-ray services. You say that the portable x-ray services should be 
paid as billed because they were coded correctly and are supported in the documentation. The Plan denied your request. The Plan says the portable x-ray services are denied because they were performed while the enrollee 
was in a covered SNF stay, so they are included in the SNF PPS (Prospective Payment System) rate. 
 
The Plan must follow Medicare rules. Medicare rules say that when a SNF resident receives a portable x-ray 
service, only the service's professional component is a separately billable physican service under Part B.  
 
We looked at the file and Medicare rules. We confirmed that codes R0070, defined as transportation of portable 
x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen, and 
Q0092, defined as set-up portable x-ray equipment, have a professional component (PC)/technical component 
(TC) flag of 3. This indicator identifies stand-alone codes that describe the technical component (for example, 
staff and equipment costs) of selected diagnostic tests only. We confirmed that in this case, codes 73090, 
73120, and 73100 were billed with modifier -TC, also indicating the technical component only. According to 
Medicare rules, when an enrollee receives a portable x-ray service during the course of a Part A covered SNF 
stay, the technical component of a procedure, including any associated transportation and set up costs, must be 
included on the SNF's Part A bill for the enrollee's covered stay. The technical component is not separately 
billable by the physican under Part B. Based on this information, we decided that Medicare rules for coverage 
of the portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for 
the portable x-ray services described by codes R0070, Q0092, 73090-TC, 73120-TC, and 73100-TC billed on 
March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on February 27, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on March 6, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on March 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that medical studies have not proven that this procedure is helpful treatment 
for lumbar radiculopathy.  
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition. No compelling rationale is 
presented, or extenuating circumstances noted, to support the medical necessity of this request as an exception. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spinal surgery.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 20, 2023, 
to March 7, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that this claim was billed correctly. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 20, 2023, to 
March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483).  
You asked the Plan to pre-approve definitive UDT for 22 or more drug classes. You say that this test is crucial 
component of their pain management regimen, ensuring safety and effectiveness while preventing medication 
misuse. The Plan denied your request. The Plan says no information provided that the enrollee has had 
inconsistency or special circumstances requiring testing of this many classes of drugs. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that in this 
case, there was no specific medical rationale for the requested drug testing. There was no information provided 
that the enrollee has had inconsistency or special circumstances requiring testing of this many classes of drugs. 
The review has determined that the enrollee does not meet the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive UDT for 22 or more drug classes have not been met. Therefore, we 
decided that the Plan does not have to pre-approve definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 17, 2023, to May 
16, 2023. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 17, 2023. The NOA was not received by the Plan until July 11, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
April 17, 2023, to May 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 10, 2023. 
 You asked the Plan to pay for the medical services. You say that the medical services were provided based on 
the patients condition. The Plan denied your request. The Plan says the diagnosis code at issue is not 
appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code N48.30 (Priapism, 
unspecified). This code is not an appropriate primary diagnosis as the code has a Code first note indicating to 
code the underlying condition first. Based on this information, we decided that Medicare rules for payment of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for medical services 
provided on May 10, 2023.