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

 
We decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, spinal canal 
(72148) 
 
You asked the Plan to pre-approve a Magnetic resonance imaging. You say that you have had the proper 
treatment in order to receive an MRI. The Plan denied your request. The Plan says the medical records do not 
show you have failed a six-week trial of provider- directed treatment within the last three months, with 
documentation of a clinical re-evaluation after this treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 a Magnetic resonance imaging. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation of any clinical reasons that prevent you from being able to complete a six-week trial of 
provider-directed treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Magnetic resonance imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, spinal canal (72148)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223, & 99233 provided on September 14, 
2022 to September 19, 2022. 
 
You asked the Plan to pay for procedure codes 99223, & 99233. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the records do not support the billed services. 
 
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 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 codes 99223, & 99233. Our reviewer says that the 
codes billed are not supported by the records. Our reviewer found records do not support a comprehensive 
exam, a comprehensive history or medical decision making of high complexity, so procedure code 99223 is not 
justified. The documentation does not support an appropriate interval history or exam, so procedure code 99233 is not supported. 
 
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 codes 99223, & 99233 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 99223, & 99233 provided on September 14, 2022 to 
September 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT). 
 
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 if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records adequately 
demonstrate the need for IMRT using dosimetric evidence with documentation that a conventional three-
dimensional (3D) conformal plan was unacceptable for this enrollee. The use of IMRT is the standard of care 
for the enrollee's condition and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve intensity modulated radiation therapy (IMRT).  
 
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 87481, 87653, 87798, and 87801 billed for 
date of service February 2, 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 the services are not covered. 
 
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, and 87798 are a column II code to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate and distinct procedural 
service. Based on the claim submitted, Medicare billing criteria have not been met. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the records do not support 
the multiple organisms described by the code were tested. 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 87481, 87653, 87798, and 87801 
billed for date of service February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673). 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and would like reconsideration. The Plan denied your request. The Plan says a PCD is not 
covered by Medicare when the place of service is an ambulatory surgical center. The Plan follows Medicare rules. The rules say that a PCD's are not covered by Medicare when the place of 
service is an ambulatory surgical center. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. The records show that a place of service billed was 24, which is an 
ambulatory surgical center. Specifically, the PCD was billed for use outside of the enrollee's home and is not 
separately payable. Therefore, we decided that the Plan does not have to pay for a pneumatic compression 
device (E0675) and a segmental gradient pressure pneumatic appliance, half leg (E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a power lift chair purchased April 22, 2023. 
 
You asked the Plan to reimburse you for a power lift chair. You say that you were told by a Plan representative 
that if your doctor wrote a letter stating that you needed the chair for health reasons then it would be covered. 
The Plan denied your request. The Plan says the durable medical equipment was purchased from a non-
Medicare participating, out of network provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for a power lift chair purchased 
April 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon. 
 
You asked the Plan to pre-approve these services. You say that the in-network provider did not recommend 
surgery and you were hoping for help sooner. The Plan denied your request. The Plan says the services are 
available from network providers. 
 
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. The Plan confirmed they have network providers available from which you have not previously received services. 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 referral to an out-of-network orthopedic surgeon.
Appeal type: Lab
Decision: Partially Favorable

 
You asked the Plan to pay for lab codes 87801, 87481-XU, 87653-XU, and 87798-XU provided on February 
15, 2023. You say that you are appealing with supporting records. The Plan says that code 87801 represents 
multiple organisms, but the records do not indicate which organisms were tested by the panel. The Plan also 
says that codes 87481, 87653, and 87798 are included in code 87801 so are not separately payable. 
 
We decided that the Plan has to pay for 87801.  
 
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 87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. 
 
We asked our coding 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 87801. Our reviewer says that code 87801 
meets criteria for payment. Our physician reviewer found the medical records included documentation of 
testing billed with code 87801 and 87798; therefore, this procedure code should be covered.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87801, 87481-XU, 87653-XU, and 87798-XU have been met. Therefore, we 
decided that the Plan has to pay for 87801.  
 
We also decided that the Plan does not have to pay for 87481-XU, 87653-XU, and 87798-XU. 
 
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 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 87481-XU, 87653-XU, and 87798-XU. Our reviewer says 
that these codes are not supported for payment. Our reviewer found the laboratory report does not include 
documentation to support the procedure codes with modifier -XU and therefore these codes would be included 
in code 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87481-XU, 87653-XU, and 87798-XU have not been met. Therefore, we 
decided that the Plan does not have to pay for 87481-XU, 87653-XU, and 87798-XU. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97112, 97140, and 97032 billed for 
February 1, 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 97110, 97112, 97140, and 97032 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 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 97140 is manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. The definition 
of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. 
 
We find that CPT codes 97110, 97112, 97140, and 97032 are not supported in the medical record. Specifically, 
the records do not document that at least eight minutes of therapy were performed for each billed code, which 
is the minimum requirement for service time.  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 97110, 97112, 97140, and 97032 billed for February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient left atrial appendage closure (LAAC) 
procedure. 
 
You asked the Plan to pre-approve the LAAC procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the ordering physician has not deemed that the enrollee 
is unable to take anticoagulant alternatives, and therefore, the requested procedure is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that a. LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet certain criteria. 
 
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 LAAC procedure. Our reviewer 
says that the requested LAAC procedure is not medically necessary. Our physician reviewer found the 
documentation indicates the enrollee has an elevated risk of thromboembolic stroke due to atrial fibrillation and 
high CHADS2VASC score. The provided documentation does not indicate any contraindication to 
anticoagulation according to the physician. As such, guidelines would not support implantation of a LAAC in 
this setting. Therefore, the reviewer found that the requested LAAC placement 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 LAAC procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient left atrial appendage closure (LAAC) procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 provided on March 24, 2023 
 
You asked the Plan to pay for procedure code 81479. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 81479 is not supported in the medical record. Specifically, there is no documentation 
describing testing on a sample collected on the date of service at issue. Therefore, we decided that the Plan 
does not have to pay for procedure code 81479 provided on March 24, 2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need assistance to walk and require IRF services 
to regain your prior level of functioning. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an EMST150 expiratory muscle trainer. 
 
You asked the Plan to pre-approve an EMST150 expiratory muscle trainer. You say that the requested item is a 
necessity for your care. The Plan denied your request. The Plan says the requested item does not serve a 
primarily medical purpose. 
 
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 an EMST150 expiratory muscle trainer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 15, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the leadless pacemaker insertion rendered on September 28, 
2021. 
 
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 the claim was not billed with the required clinical trial number. 
 
The Plan must follow Medicare rules. The rules say that it is mandatory to report a clinical trial number on 
claims for items/services provided in clinical trials/studies/registries, or under Coverage with Evidence 
Development (CED). 
 
We looked at the file and Medicare rules. The file shows that the clinical trial number was not billed on the 
claim. 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 the leadless pacemaker insertion rendered on 
September 28, 2021.