Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 27, 2023, billed with 
evaluation and management code 99213-25. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed 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 99213-25 is a column II code to column I code 36482; however, 
99213-25 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the patient came into clinic for review 
and interpretation of the enlarged vestibular aqueduct (EVA) and the procedure performed. There is no need for 
an additional evaluation to be billed. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 27, 2023, billed with evaluation and 
management code 99213-25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve destruction. 
 
You asked the Plan to pre-approve genicular nerve destruction. You say that the enrollee is in pain. The Plan 
denied your request. The Plan says this 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 genicular nerve destruction. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental/investigational and is the subject 
of ongoing clinical trials. 
 
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 nerve destruction have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve destruction.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that the services were rendered for the benefit of the 
enrollee. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 18, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 billed for date of service May 6, 2023.  
 You asked the Plan to pay for procedure code 93970. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93970 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93970 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93970 billed for date of service May 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do 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 records indicate you are not currently on insulin or have a history of low blood sugar levels. 
 
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 freestyle libre 3 continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the drug. You say that that the medication was previously approved. You 
say that the patient has been tolerating the medication without adverse effects. The Plan denied your request. 
The Plan says the requested drug is not being furnished by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99204 and 
the x-ray services coded as 72040 performed on May 10, 2023. 
 
You asked the Plan to pay for 99204 and 72040. You say that 99204 and 72040 should be covered because 
these services were necessary to treat constant pain from degenerative disks that has not been helped by other 
treatment options you have tried. The Plan denied your request. The Plan says 99204 and 72040 are not 
covered when performed by a chiropractor, as they were in this case. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue, 99204 and 72040, are not manual manipulation of the spine. 
Therefore, we decided that the Plan does not have to pay for the evaluation and management services coded as 
99204 and the x-ray services coded as 72040 performed on May 10, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 83921 billed for date of service January 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that physician's send specimens for testing. The Plan 
denied your request. The Plan says that the documentation did not include lab results for the billed date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 83921 is supported in the medical record. The documentation shows that the specimen 
was collected on January 3, 2023. The test/service must be the date the specimen was collected. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure code 83921 billed for date of service January 3, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring Device (K1024 and K1033). 
 
You asked the Plan to pre-approve a Koya Dayspring Device (K1024 and K1033). You say that the requested 
Koys Dayspring Device is medically necessary. The Plan denied your request. The Plan says the requested 
Koys Dayspring Device 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 Koya Dayspring Device (K1024 and 
K1033). Our reviewer says that the requested Koys Dayspring Device is not medically necessary. Our 
physician reviewer found the enrollee is noted to have chronic lymphedema affecting the lower extremities. 
The documentation indicates that the enrollee has tried conservative measures, including compression garments 
and elevation. She has also trialed a basic pneumatic compression device, but there is insufficient documentation regarding a failure to respond with objective measurements. There is also a lack of medical 
literature indicating that the requested Koya Dayspring Device non-pneumatic compression device is clinically 
as or more efficacious than standard pneumatic compression devices. The medical literature largely includes 
pilot studies with a small number of participants. 
 
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 Koya Dayspring Device (K1024 and K1033) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Koya Dayspring Device (K1024 and K1033).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service February 21, 
2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99291 is bundled into 
payment for code 92950. 
 
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 99291 
is a column II code to column I code 92950. 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 procedure code 99291 billed for date of service February 21, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy billed for dates of service March 1, 
2023, to March 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that the records support the services rendered. The 
Plan denied your request. The Plan says the billed codes 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. 
 
We find that CPT codes 97530, 97161, and 97110 were billed with the GP modifier. The records do not include 
a plan of care for the services at issue. 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 
physical therapy billed for dates of service March 1, 2023, to March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator device (K1019). 
 
You asked the Plan to pay for the Cala Trio nerve stimulator device. You say that this item is medically 
necessary. The Plan denied your request. The Plan says the device is considered experimental. 
 
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 Cala Trio nerve stimulator device. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the device is considered experimental.  
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 Cala Trio nerve stimulator device have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cala Trio nerve stimulator device (K1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 16, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says these are non-covered services. The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare. Therefore, we decided that the Plan does not have to pay for Outpatient Intravenous Insulin 
Therapy (OIVIT) services provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 billed for date of service April 6, 2023. 
 
You asked the Plan to pay for code 99291. You say that the medical records show the dictation time and date 
and the transcription date and time.  This is the actual time when the service was rendered. The Plan denied 
your request. The Plan says the submitted medical records include a critical care note; however, the note 
doesn't include the actual date of service. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes on a given calendar date of service. 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, there is no actual date of 
service noted in the medical records.  Although a dictation and transcription date and time are provided, these 
are not necessarily the same as the date when the service was rendered.  The medical records must show when 
the service was actually rendered, and that is missing in this case. Based on this information, we decided that 
Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99291 billed for date of service April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for G0481 billed for date of service October 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that the physician's send specimens for testing. The 
Plan denied your request. The Plan says the accuracy of the code cannot be verified. 
 
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 G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. The medical records provided do not show 
that 8-14 drug classes were tested. 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 G0481 
billed for date of service October 12, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 testing provided on April 5, 2023. 
 
You asked the Plan to pay for Guardant360 testing. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that the claim for this molecular pathology testing did not include 
the required unique identifier. 
 
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 rules also say that for molecular diagnostic tests, such as the test at issue, the MolDX program 
requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are 
met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in 
the DEXTM Diagnostics Exchange. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan states that the required unique identifier was not reported. 
Our review of the claim does not support the Plan's assertion. It is the Plan's responsibility to support its denial. 
In this case, the Plan's denial is not supported, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for Guardant360 testing provided on April 5, 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has not been shown to be safe and effective for treatment of the enrollee's 
condition. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion 
interspinous spacer at L2-4, in this case, 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve the medication. You say that the patient's condition is controlled on this 
medication, and any interruption in therapy could result in a serious cardiac event. You also say that this 
medication is medically necessary. 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 Repatha Sureclick.  
 
Benefits for the medication 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 lab services provided on February 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 February 25, 2022.