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

 
We decided that the Plan does not have to pay for code G0318 billed for date of service May 23, 2023. 
 
You asked the Plan to pay for code G0318. You say that payment for this code should not have been bundled. 
The Plan denied your request. The Plan says the service at issue was not billed with the required modifier to 
allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 
11721-Q8 provided on May 23, 2023. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for code G0318 billed for 
date of service May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel (87801, 
87798, 87481 and 87150) provided on March 20, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says this test was 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 pay for the urine PCR panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation as to why this was sent rather than a basic urinalysis and reflex 
culture. 
 
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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine PCR (polymerase chain reaction) panel (87801, 87798, 87481 and 87150) 
provided on March 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on March 12, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the medical records 
support the necessity for the ambulance transport. The Plan denied your request. The Plan says our records 
indicate this pre-approval was not obtained. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance transport services were not medically necessary. Our physician reviewer 
found the transportation via ambulance upon being discharged from the emergency department was not 
medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport.   
 Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. A prudent person would not believe that immediate medical 
attention was required for someone who was being discharged from the emergency department/hospital. 
 
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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on March 12, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the gastrointestinal pathogen panel (code 87507) billed for date of 
service April 6, 2023. 
 
You asked the Plan to pay for code 87507. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says that this test was not medically necessary. The Plan cited to a local coverage 
article, but that article does not state that any diagnosis codes not listed are automatically considered not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for code 87507. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records confirmed that you had diarrhea.  A stool pathogen panel is considered 
medically necessary and reasonable in this scenario. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87507 have been met. Therefore, we decided that the Plan has to pay for 
the gastrointestinal pathogen panel (code 87507) billed for date of service April 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says the 
records show that you used 36 trips of the 36 allowed by the Plan. The Plan also says that your request for an 
additional 20 trips exceeds the maximum transportation benefit allowed per the plan 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance urinary tract infection (UTI) panel (87801, 
87481, 87500, 87511, 87640, 87653 and 87798) provided on March 21, 2023. 
 
You asked the Plan to pay for the Guidance UTI panel. You say that this test was medically necessary and 
reasonable. The Plan denied your request. The Plan says this test is not medically necessary by Medicare rules. 
 
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 Guidance UTI panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation is to why a basic urinalysis with reflex culture was 
insufficient. 
 
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 Guidance UTI panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guidance urinary tract infection (UTI) panel (87801, 87481, 87500, 87511, 87640, 
87653 and 87798) provided on March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound panel (87481, 87641, 87798, 87640, 87500, 
87651, 87471, 87493, 87529, 87563, 87653 and 87561) provided on May 8, 2023. 
 You asked the Plan to pay for the wound panel. You say that this test was medically necessary and is supported 
as billed. The Plan denied your request. The Plan says this panel was not billed appropriately and does not 
include sufficient records to support 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 wound panel have been met. 
Specifically, the order form for this panel includes an illegible signature and there are no physician notes or 
medical records to support the medical necessity of this test and to show that the enrollee's treating physician 
had the intent for it to be performed.. Therefore, we decided that the Plan does not have to pay for the wound 
panel (87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 87563, 87653 and 87561) provided 
on May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopy services (00813) provided on March 4, 2023. 
 
You asked the Plan to pay for endoscopy services. You say that this procedure was necessary and is payable. 
The Plan denied your request. The Plan says this claim should be submitted to the enrollee's primary insurer 
before additional payment may be made. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for 
endoscopy services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for endoscopy services (00813) provided on March 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97803 billed for dates of service December 
20, 2022, to April 13, 2023.  
 You asked the Plan to pay for procedure code 97803. You say that the patient was referred by their primary 
care physician. The Plan denied your request. The Plan says payment for code 97803 for date of service 
December 20, 2022, is bundled into payment for code G0270. Code 97803 billed for the other dates of service 
is not covered because you billed it with an incorrect pair of diagnoses. 
 
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 relation to code 97803 billed for date of 
service December 20, 2022, we have confirmed that code 97803 is a column II code to column I code G0270 
with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, 
Medicare billing criteria have not been met.  
 
In relation to code 97803 billed on the other dates of service at appeal, Medicare rules say that diagnosis codes 
with an Excludes1 note indicates that the code excluded should never be used at the same time as the code 
above the Excludes1 note. 
 
In this case, you billed the claims for code 97803 with diagnoses of E11.9 and E08.40. Code E08.40 is an 
Excludes1 code under code E11.9, so these two diagnoses cannot be billed together. 
 
Therefore, we decided that the Plan does not have to pay for procedure code 97803 billed for dates of service 
December 20, 2022, to April 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support the necessity for admission to an IRF. The 
complexity of your medical, rehabilitation, and nursing needs does not require an acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be 
safely provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  the service is medically necessary.  The 
Plan denied your request. The Plan says  the LTACH services are not medically necessary, and the enrollee's 
needs can be met at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute on chronic respiratory failure in the setting of 
sepsis secondary to post obstructive pneumonia and a history of chemotherapy. The record indicates that the 
enrollee has ongoing acute medical issues and still requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on February 16, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under the 
supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  
 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on February 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee is an appropriate candidate for treatment 
with lecanemab. The Plan denied your request. The Plan says Leqembi is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that 
Leqembi is not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
moderate dementia in the setting of late onset Alzheimer's disease. The FDA has not stated that the requested 
drug is indicated for the enrollee's condition. The requested drug is also not supported by one of the major drug 
compendia for the enrollee's clinical situation. Therefore, the elements of the coverage criteria are not satisfied, 
and the requested service cannot be recommended.  
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a disposable drug delivery system (A4305) and supplies 
(A4221, A4222). 
 
You asked the Plan to pay for a disposable drug delivery system and supplies. You say that the item should be 
covered. The Plan denied your request. The Plan says these are non-covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. Drugs and supplies used with disposable drug delivery 
systems are also non-covered items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a disposable drug delivery system and supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for a disposable drug delivery system (A4305) and supplies (A4221, A4222).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive percutaneous left sacroiliac (SI) 
fusion (27279, 0775T). 
 
You asked the Plan to pre-approve minimally invasive percutaneous left SI fusion. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 minimally invasive percutaneous left SI 
fusion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested minimally invasive percutaneous left SI fusion 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 minimally invasive percutaneous left SI fusion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve minimally invasive percutaneous left sacroiliac (SI) 
fusion (27279, 0775T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve the medication. You say that the medication is 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 Eliquis.   
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 Guidance UTI testing (87481, 87500, 87511, 87640, 87653, 
87798 and 87801) provided on April 15, 2023. 
 
You asked the Plan to pay for Guidance UTI testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guidance UTI testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guidance UTI testing (87481, 87500, 87511, 87640, 87653, 87798 and 87801) 
provided on April 15, 2023.