Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 4, 2023, to 
February 2, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 January 4, 2023, to 
February 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lonsurf. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lonsurf.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says the non-
invasive ventilator requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
the provided records in this case document a diagnosis of chronic respiratory failure with a history of obesity 
hypoventilation syndrome and heart failure. Medical records do not document a neuromuscular disease or any 
objective testing showing thoracic restrictive disease, or chronic respiratory failure consequent to COPD. Our 
reviewer found that the records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-expiratory positive airway pressure which could be 
provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. Our physician 
reviewer also found that the provided records in this case do not provide adequate detailed information to meet 
Medicare criteria for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87798 billed for date of service 
March 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that records were submitted. The Plan denied your 
request. The Plan says payment for code 87150 is bundled into payment for code 87500. 
 
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 87150 is a column II code to column I code 87500, and code 87798 is 
a column II code to column I code 87801. CPT codes 87150 and 87798 were billed with the -01 modifier. 
However, the records do not show that the tests were performed more than once on the same day. The codes at 
issue have not been billed with an appropriate modifier to bypass the edit. 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 87150 and 87798 billed for date of service March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80050, 83036, 84480, 83721 and 84436 
billed for date of service July 25, 2022.  
 
You asked the Plan to pay for procedure codes 80050, 83036, 84480, 83721 and 84436. You say that these 
services were necessary and are supported in the medical record. The Plan denied your request. The Plan says 
payment for codes 84480, 83721 and 84436 is bundled into payment for codes 84481, 83701 and 84439. In 
addition, code 80050 is not payable by Medicare and 83036 was provided as a non-covered screening. 
 
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 
84480, 83721 and 84436 are column II codes to column I codes 84481, 83701 and 84439, respectively. Each of 
these code pairs has a modifier indicator of 0. The column II codes are therefore not payable.  
 
The rules also say that code 80050 (general health panel) is considered a non-covered code. You have 
requested payment for services billed under code 80050. Medicare does not cover or pay for services billed 
under this code. 
 
The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules 
section, are not covered. Procedure code 83036, hemoglobin; glycosylated (A1C), was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. 
 
Based on the claim submitted, Medicare criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 80050, 83036, 84480, 83721 and 84436 billed for date of service July 25, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months of continued use of a home ventilator 
(E0466). 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that the enrollee has tried a 
BiPap with no relief. The Plan denied your request. The Plan says the request for continued use of non-invasive 
ventilator (NIV) is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 

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 continued use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of chronic respiratory failure consequent to thoracic restrictive disease. Provided records do not 
document the mode in which the home ventilator is to be used. Provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not reasonable and necessary." The LCD requires: "There must be enough 
detailed information in the medical record to justify the treatment selected." Provided records in this case do 
not provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as opposed to a 
BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve nine (9) months of continued use of a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 for date of service December 29, 
2022, and December 30, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was billed with 
diagnosis code F05 (Delirium due to known physiological condition). This diagnosis code has a code first note 
meaning an underlying condition should be sequenced first. This code is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99232 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99232 for date of service 
December 29, 2022, and December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Restore-X Penile Traction Therapy device. 
 
You asked the Plan to pre-approve a Restore-X Penile Traction Therapy device. You say that you do not think 
the denial is fair because you upgraded your insurance and pay a $29 premium for this not to be covered under 
your medical. You also say that if you had the money, you would buy it yourself. The Plan denied your request. 
The Plan says at this time, there is no information or evidence as to the clinical effectiveness, and thus this item 
would be considered experimental and investigational. 
 
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 a Restore-X Penile Traction Therapy 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Restore-X Penile Traction Therapy device is not 
considered to be a medically necessary treatment by Medicare. 
 
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 Restore-X Penile Traction Therapy device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Restore-X Penile Traction Therapy device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement (11012) and skin substitute graft (15275) 
provided on December 2, 2022. 
 
You asked the Plan to pay for debridement (11012) and skin substitute graft (15275). You say that the services 
were ordered by the in-network surgeon in the interest of the enrollee's safety. You say that the decision should 
be reversed, and additional payment made. The Plan denied your request. The Plan says assistants surgeons 
may not be paid for these services. 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 11012 and 15275. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon 
is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for debridement (11012) and skin substitute graft (15275) have not been met. Therefore, we decided 
that the Plan does not have to pay for debridement (11012) and skin substitute graft (15275) provided on 
December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99498 billed for December 11, 2021. 
 
You asked the Plan to pay for code 99498. The Plan denied your request. The Plan says the add-on code was 
not billed with an appropriate primary code. 
 
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 99498 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for code 99498 billed for December 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the requirements for approval. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for COPD exacerbation. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical 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 you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that genicular artery embolization is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says genicular artery embolization 
is experimental/investigational. 
 
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 genicular artery embolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that genicular artery embolization is considered an experimental/ investigational 
procedure 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is on the self-administered drug list and is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter mitral valve repair (TMVR) procedure. 
 
You asked the Plan to pre-approve a TMVR procedure. You say that a TMVR procedure is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says a TMVR procedure is 
experimental/investigational. 
 
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 a TMVR procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has tricuspid regurgitation. The provided documentation is inadequate to 
confirm fulfillment of published guidelines for TMVR. 
 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 TMVR procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter mitral valve repair (TMVR) procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0482) rendered from 
October 3, 2022 to November 3, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in 
clinical management, exceeds the needs of the enrollee. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the enrollee did not require this level of drug testing. It was not 
necessary to test for 15-21 drug classes. The reviewed documentation indicates that the diagnosis is medication 
management of long term (current) drug therapy. The medical record sent by the provider shows presumptive 
screening test results which are partially inconsistent with prescription medications, or history and expected 
results. Definitive confirmation testing was medically necessary for only 1 drug class: Oxycodone. 
 
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 pay for drug testing services (procedure code G0482) rendered from October 3, 2022 to November 3, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that it seems that a positive airway pressure (PAP) 
machine cannot provide enough pressure. The Plan denied your request. The Plan says a ventilator is not 
covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0127 billed for date of service February 20, 
2023. 
 You asked the Plan to pay for the billed services. You say that the code does not require an anatomical 
modifier. The Plan denied your request. The Plan says there are specific anatomic toe modifiers. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We looked at the file and the rules. The medical records do not show that the service billed with the -59 
modifier was a distinct procedural service. Modifier 59 should be used when a service cannot be described by 
one of the more specific anatomic modifiers. 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 
G0127 billed for date of service February 20, 2023.