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

 
We decided that the Plan does not have to pay for radiologic examination (x-ray) of the chest (71045) provided 
on June 18, 2023. 
 You asked the Plan to pay for procedure code 71045-26. You say that the service was billed correctly, and the 
claim should be paid. The Plan denied your request. The Plan says payment for code 71045-26 is bundled into 
payment for code 71048-26. 
 
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 
71045-26 is a column II code to column I code 71048-26. This claim has 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 radiologic examination (x-ray) of the chest 
(71045) provided on June 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel. 
 
You asked the Plan to pre-approve Enbrel. 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 Enbrel.  Benefits for Enbrel may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 13, 2022. 
 
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 a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
unit of one code as required by LCA A58720. 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 July 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for military hospital services provided on May 13, 2022. 
 
You asked the Plan to pay for military hospital services. You say that this claim must be paid according to 
United States law. The Plan denied your request. The Plan says Medicare cannot make payment for Veterans' 
Administration services. 
 
The Plan must follow Medicare rules. Medicare rules say that in general, Medicare payment may not be made 
for items and services furnished by a provider (Governmental or non governmental) or other person at public 
expense pursuant to an authorization issued by a Federal agency; furnished by a provider of services or agency 
of the Federal government ; and paid for directly or indirectly by a Federal, State, or local governmental entity.  
We looked at the file and Medicare rules. The services at issue were provided by a military hospital, which is 
considered a government entity. Based on this information, we decided that Medicare rules for coverage of 
military hospital services have not been met. Therefore, we decided that the Plan does not have to pay for 
military hospital services provided on May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00731) rendered on 
January 3, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee's diagnosis did not require anesthesia. 
 
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 in this case, there was no documentation of a specific medical indication for the use of monitored 
anesthesia care. The review has determined that the enrollee did not require anesthesia in this case. The intra-
operative anesthesiology record was not available in the records submitted. There was no documentation of the 
intra-operative anesthesia care/intra-operative monitoring. There was also no post-anesthesia care unit (PACU) 
evaluation/note provided. The billed services were not supported, as they could not be verified. 
 
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 anesthesia services (procedure code 00731) rendered on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0825). 
 
You asked the Plan to pre-approve a  power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says the requested power wheelchair exceeds the enrollee's 
needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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  power wheelchair. Our reviewer says 
that the requested power wheelchair is not medically necessary. Our physician reviewer found the clinical 
documentation is insufficient why the patient requires a group 2 power wheelchair versus a group 1 power 
mobility device or power scooter. She is noted to have full motor strength in the upper and lower extremities 
and is independent transfer and can operate the tiller system. 
 
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  power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0825).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx Urinary Tract Infection (UTI) panel provided 
on January 12, 2023. 
 
You asked the Plan to pay for the Altru Dx UTI panel. You say that this testing was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this panel is not medically necessary as it is 
not the standard of care. 
 
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 Altru Dx UTI panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this test is a urine polymerase chain reaction (PCR) panel, which is not considered 
reasonable or necessary. Urine culture is the standard of care for working up UTIs. 
 
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 Altru Dx UTI panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the Altru Dx Urinary Tract Infection (UTI) panel provided on January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93247 for date of service April 1, 2023. 
 
You asked the Plan to pay for procedure code 93247. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93247 is external electrocardiographic recording for more 
than 7 days up to 15 days by continuous rhythm recording and storage; scanning analysis with report. 
 
We find that CPT code 93247 is not supported in the medical record. Specifically, the medical records 
submitted don't include external electrocardiographic recording for more than 7 days up to 15 days by 
continuous rhythm recording and storage; scanning analysis with report for the billed date of service was 
performed. Therefore, this code is not supported. Based on this information, we decided that Medicare rules for coverage of procedure code 93247 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 93247 for date of service April 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shower/bath chair to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the shower/bath chair. You say that you did not want the surgery incision to 
get wet. The Plan denied your request. The Plan says the enrollee must receive your care from a network 
provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plan's network) will not be covered. 
 
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. 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 
the shower/bath chair to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion W orthotic device (L8701). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
internist for myoelectric orthotic restoration, using the MyoPro Motion W. The Plan denied your request. The 
Plan says this is considered experimental and investigational due to insufficient evidence of safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion W orthotic device (L8701).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the diabetic shoes (A5500) and inserts (A5512). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that the items should be covered. 
The Plan denied your request. The Plan says that the items are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit any indication as to why this claim was denied. 
Therefore, we decided that the Plan has to pre-approve the diabetic shoes (A5500) and inserts (A5512).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician attendance and supervision of hyperbaric 
oxygen therapy (99183) provided on January 3, 2022. 
 
You asked the Plan to pay for the physician attendance and supervision of hyperbaric oxygen therapy. You say 
that the service should be covered. The Plan denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician attendance and supervision of hyperbaric oxygen therapy was 
not filed until April 6, 2023. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for the physician attendance 
and supervision of hyperbaric oxygen therapy (99183) provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says a genicular nerve block 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary. Our 
physician reviewer found that a genicular nerve block is experimental for knee pain. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves (A4927). 
 
You asked the Plan to pre-approve non-sterile gloves. You say that the worker uses the gloves to clean the 
enrollee. The Plan denied your request. The Plan says disposable gloves are not covered because they are 
hygienic items that are non-reusable. 
 
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 non-sterile gloves (A4927).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves. 
 
You asked the Plan to pre-approve the requested items. You say that you need gloves to change your ostomy 
bag. The Plan denied your request. The Plan says the request is not a covered benefit. 
 
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 non-sterile gloves.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical examination provided on June 28, 2023. 
 
You asked the Plan to pay for the physical examination. The Plan denied your request. The Plan says the 
services are not a covered benefit. 
 
The Plan contract says physical exams for the following reasons: employment, licensing, insurance coverage 
(i.e. pilot licenses, commercial driver license, etc.) are not covered under any condition. 
 
We looked at the file and the Plans rules. The file shows that the physical examination is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for a physical examination provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service January 17, 
2023.  
 
You asked the Plan to pay for procedure code 99222. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99222 is bundled into payment for code 
99223. 
 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 99222 
is a column two code to column one code 99223 with a modifier indicator of 0. The column two 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 99222 billed for date of service January 17, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction device billed for date of service April 2, 
2023. 
 
You asked the Plan to pay for the billed services. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says the coverage criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that cervical traction devices are only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. We find that the provided device is not supported in the medical 
record. The records do document that the enrollee has cervicalgia requiring a brace. However, the medical 
records do not include a treatment plan for a traction device for greater than 20 pounds of cervical traction in 
the home setting. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the cervical traction device 
billed for date of service April 2, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on January 16, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the medical records do not support the 
billing of code G0483. 
 
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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records show that more than 
22 drug classes were tested, including Amphetamines, Antidepressants-serotonergic class, Antidepressants-
tricyclic and other cyclicals, Barbiturates, Benzodiazepines, Buprenorphine, Cannabinoids-natural, Cocaine, 
Fentanyl's, Heroin metabolite, Ketamine and Norketamine, Methadone, Methylenedioxyamphetamines, 
Methylphenidate, Opiates, Opioids and opiate analogs, Oxycodone, Phencyclidine, Propoxyphene, Sedative 
Hypnotics (non-benzodiazepines), Skeletal muscle relaxants, Tapentadol, and Tramadol. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0483 have been met. Therefore, 
we decided that the Plan has to pay for procedure code G0483 provided on January 16, 2023.  
 
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.