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

 
We decided that the Plan does not have to pay for physician services (99223) provided on December 20, 2022 
to December 21, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 99223 is initial hospital inpatient or observation care 
provided by a healthcare professional for the evaluation and management of a patient, requiring a medically 
appropriate history and/or examination and high level of medical decision making. 
 
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 physician services. Our reviewer says that the records do 
not support the billed services. Our reviewer found there was no documentation of a comprehensive 
examination. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on December 20, 2022 to December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 18, 
2022.  
 You asked the Plan to pay for procedure code 0003A. You say that this is a covered service and this claim 
should be paid. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95927, 95937 and 95955 billed for date of 
service February 9, 2021. 
 
You asked the Plan to pay for procedure codes 95927, 95937 and 95955. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
services 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. 
 
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 95927, 95937 and 95955. Our reviewer says 
that procedure codes 95927, 95937 and 95955 do not meet criteria for payment. Our reviewer found that the 
procedure report does not include documentation of procedure code 95927, short-latency somatosensory evoked potential (SSEP) stimulation of any/all peripheral nerves or skin sites, recording from the central 
nervous system (CNS), in the trunk or head. Therefore, this procedure cannot be verified. The procedure report 
does not include documentation of procedure code 95937, neuromuscular junction testing, as the report 
describes T04. A CPT code does not exist for T04, as this procedure is included in the primary 
neuromonitoring procedure codes. The procedure report does not include documentation of procedure code 
95955, EEG during nonintracranial surgery (eg, carotid surgery). Therefore, this procedure cannot be verified. 
 
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 95927, 95937 and 95955 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95927, 95937 and 95955 billed for date of 
service February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 26, 
2022.  
 You asked the Plan to pay for procedure code 0003A. You say that this is a covered service and this claim 
should be paid. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connector (E2310) and an attendant 
control (E2331). 
 
You asked the Plan to pre-approve an electronic connector and an attendant control. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says that an electronic connector is not 
medically necessary. The Plan also says that an attendant control is not covered with a beneficiary-operated 
drive control system. 
 
The Plan follows Medicare rules. Medicare rules say that an electronic connector is covered when it is 
necessary to control the power options through a joystick. The rules also say if an attendant control is provided 
in addition to a beneficiary-operated drive control system, it will be denied as non-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 an electronic connector. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the provided records 
document that the enrollee has 0/5 left upper extremity strength but the records do not document weakness or 
loss of function of the right upper extremity to require a joystick to operate the wheelchairs power options. 
The records do not clarify if the enrollee could not operate the wheelchairs power options with their own 
switches with his right upper extremity.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connector have not been met. An attendant control is not covered 
when provided in addition to a beneficiary-operated drive control system. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connector (E2310) and an attendant control (E2331).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 21, 2022, to 
November 30, 2022. 
 You asked the Plan to pay for the home health services. You say that you billed these services with the correct 
Type of Bill. The Plan denied your request. The Plan says the NOA was not received. As such, this final claim 
was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, you have not submitted the required NOA to the Plan. As a result, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
November 21, 2022, to November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve  a TouchTalk speech generating device (E2510). 
 
You asked the Plan to pre-approve  a TouchTalk speech generating device. You say that devices from the 
Plan's network providers were already considered and ruled out as not appropriate for her. You say that the 
requested device is medically necessary and the ideal device for the enrollee's specific needs. You say that you 
are the sole provider of the TouchTalk.  The Plan denied your request. The Plan says that medically necessary 
care is available in-network.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 TouchTalk speech generating device. 
Our reviewer says that the criteria for coverage of OON care have been met.  Our physician reviewer found the 
Plan recommended instead for the enrollee to use the AbleNet brand (in-network) that offers a comparable 
device. AbleNet devices are pediatric and only allow the patient to express a limited amount of vocabulary and 
does not allow for meaningful, spontaneous speech like the requested Touch Talk device. These devices do not let the patient communicate independently like the TouchTalk device. The more capable Touch Talk device 
appears to be more appropriate and capable for this patient's condition. The Plan's denial is not medically 
justified as the recommended device (AbleNet) is not appropriate for this patient. The patient has a stroke and 
hearing loss and is an adult which makes the TouchTalk device more appropriate for her. The Plan offered a 
similar device designed for children that does not meet the standards of care for this patient. Therefore, the 
TouchTalk device should be considered medically reasonable and 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 a TouchTalk speech generating device have been met. Therefore, we decided 
that the Plan has to pre-approve  a TouchTalk speech generating device (E2510).  
 
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 the EpiSwitch Checkpoint Inhibitor Response Test (CiRT) 
rendered on August 8, 2022. 
 
You asked the Plan to pay for the test. You say that the claim should not have denied. The Plan denied your 
request. The Plan says this is not medically necessary for the diagnosis and treatment of the enrollee's illness or 
injury. 
 
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 test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found that 
the EpiSwitch Checkpoint Inhibitor Response Test (CiRT) is not considered a standard of care in determining 
the response to checkpoint inhibitors. It is not Food and Drug Administration (FDA) approved. Use is not supported by the National Comprehensive Cancer Network (NCCN) Guidelines or the medical literature. The 
service was not reasonable or medically 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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the EpiSwitch Checkpoint Inhibitor Response Test (CiRT) rendered on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal facet joint RFA.  
 
You asked the Plan to pre-approve a thermal facet joint RFA. You say that a thermal facet joint RFA is 
medically necessary. The Plan denied your request. The Plan says there is insufficient documentation as to the 
duration of relief from the prior radiofrequency procedure performed in July 2022. In addition, there is 
insufficient documentation regarding improvement in activities of daily living (ADLs) after that procedure. 
 
The Plan follows Medicare rules. Medicare rules say that pain assessment must be performed and documented 
at baseline, after each diagnostic procedure using the same pain scale for each assessment. A disability scale 
must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment). 
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 thermal facet joint RFA. Our reviewer 
says that the requested thermal facet joint RFA is not considered medically necessary in this case. Our 
physician reviewer found that there was documentation that you experienced pain relief from the prior RFA but 
not for duration or how if affected your ADLs. There were no updated clinical notes to help explain your 
current pain and how it causes a functional deficit measured on pain (e.g., verbal rating scale, Numerical Rating 
Scale, Visual Analog Scale) or disability (e.g., Pain Disability Assessment Scale, Oswestry Disability Index, 
Oswestry Low Back Pain Disability Questionnaire, Quebec Back Pain Disability Scale, Roland Morris Pain 
Scale, Back Pain Functional Scale, PROMIS profile domains) scale. The review has determined that the 
requested thermal facet joint RFA does not meet the Medicare LCD coverage criteria. 
 
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 thermal facet joint RFA have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a thermal facet joint RFA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99202) provided on January 30, 2023. 
 
You asked the Plan to pay for the physician services. 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. 
 
In this case, the CPT Code Manual definition of code 99202 is an Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and straightforward medical decision making. 
 
We find that CPT code 99202 is not supported in the medical record. Specifically, the use of modifier 25 is not 
supported. The records do not show a significant separately identifiable evaluation and management service. Based on this information, we decided that Medicare rules for coverage of the physician services have not been 
met. Therefore, we decided that the Plan does not have to pay for physician services (99202) provided on 
January 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45380 billed for date of service January 12, 
2023. 
 You asked the Plan to pay for procedure code 45380. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 45380 is bundled into payment for code 45385. 
 
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 45380 
is a column II code to column I code 45385. 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 45380 billed for date of service January 12, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic Compression Device (PCD) (E0651) 
(E0667)  
 
You asked the Plan to pre-approve the PCD. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 PCD. Our reviewer says that the 
member does not need these items. Our physician reviewer found the provided documentation did not clearly 
show the patient having fully exhausted at least 4 weeks of conservative treatments including compression 
stockings, regular exercise, and leg elevation. There was conflicting information noted suggesting she may not 
have been exercising or appropriately using compression as intended. Measurements of edema were not 
objectively noted before and after the formal trial. The notes do not clearly show the conservative treatment of 
atleast 4 weeks was recently completed and failed.   
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 PCD have not been met.  Therefore, we decided that the Plan does not have 
to pre-approve the pneumatic Compression Device (PCD) (E0651) (E0667)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 1, 2022. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that this test was requested by the treating 
physician who determined it to be medically necessary. The Plan denied your request. The Plan says 
insufficient information was provided to determine medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ConfirmMDx testing have been 
met. Specifically, no medical records or literature was provided to support the service at issue. Only lab results 
were submitted. No office or clinical notes were provided to support medical necessity of this service.  
Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 
1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 28, 2022, to 
February 26, 2022. 
 You asked the Plan to pay for the home health services. You say that because you submitted a RAP claim 
timely, this claim should be paid. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 28, 2022. The NOA was not received by the Plan until April 14, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 28, 2022, to February 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service December 
22, 2022.  
 
You asked the Plan to pay for procedure code 88341. You say that the pathology report justifies the billing. 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 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. The documentation did not show that the excess units were provided, correctly 
coded, and medically necessary. 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 88341 billed for 
date of service December 22, 2022.