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

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service November 14, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service November 14, 2022, 
billed with code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid swing and stance phase control (L5828), fluid 
stance extension (L5848), microprocessor control feature (L5856), and stance flexion feature (L5845). 
 
  You asked the Plan to pre-approve a fluid swing and stance phase control, fluid stance extension, 
microprocessor control feature, and stance flexion feature. You say that the enrollee is an active amputee who 
wears their prosthesis daily as they perform their activities of daily living. You also say that the enrollee has 
had 7 successful years of ambulation with the Ottobock Microprocessor C Knee, and they would like to 
continue living their life without the fear of component failure due to the Plan's denial of medical coverage. 
The Plan denied your request. The Plan says the requested prosthesis does not meet the enrollee's needs and 
therefore cannot be approved. 
 
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 fluid swing and stance phase control, 
fluid stance extension, microprocessor control feature, and stance flexion feature. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a review of the requested Ottobock microprocessor knee reveals the maximum weight capacity 
is 300 pounds. Our reviewer also found that the enrollee's weight exceeds this limit therefore the request is not 
appropriate nor 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 a fluid swing and stance phase control, fluid stance extension, microprocessor 
control feature, and stance flexion feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fluid swing and stance phase control (L5828), fluid stance extension (L5848), microprocessor 
control feature (L5856), and stance flexion feature (L5845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement battery. 
 
You asked the Plan to pre-approve a replacement battery. You say that you need a battery for your scooter. The 
Plan denied your request. The Plan says there is no evidence that your Medicare Provided Scooter is lost, or 
irreparably damaged, or older than 5 years, and your doctors have not reported any medical reasons why the 
equipment needs to be duplicated. Medicare would cover a new piece of equipment with proof of the damage 
or theft. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage. 
 
 
 We looked at the file and Medicare rules. Specifically, no evidence was provided showing that your previous 
scooter was lost. Based on this information, we decided that Medicare rules for coverage of a replacement 
battery have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement 
battery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code(s) 88305. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service September 20, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets inpatient rehabilitation criteria. 
The Plan denied your request. The Plan says the enrollee's records do not complex rehabilitation needs that 
require frequent evaluation by a rehabilitation doctor and an intensive team. Services needed may be provided 
safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine injection provided on March 8, 2023. 
 
You asked the Plan to pay for Bupivacaine. You say that you have billed the service at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not bene met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (62321) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for Bupivacaine injection provided on March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided January 25, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that you consider this test to be medically necessary 
given the clinical utility of the test result. The Plan denied your request. The Plan says this request for DecisionDx-SCC is not a covered benefit because this test has not been approved by MolDX as meeting 
Medicares reasonable and necessary requirement.  
 
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. Medicare rules say that payment will be made for MolDX approved 
genetic tests which are reasonable and necessary for the diagnosis or management of a disease, and in 
accordance with the test indications published by the provider. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the DecisionDx-SCC test (0315U) provided January 25, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 the Intracept procedure. 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 magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of back pain is not clear. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0012M) provided on November 18, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you have billed the service at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage reaffirmed for CPT codes 0012M 
and 0013M for CxBladder. Based on this information, we decided that Medicare rules for coverage of genetic 
testing denoted by code 0012M have not been met. Therefore, we decided that the Plan does not have to pay 
for genetic testing (0012M) provided on November 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found the records do not show x-ray 
evidence of osteoarthritis or failure of steroid injections. The review has determined that Euflexxa is not 
medically reasonable and necessary. The documentation does not support that the Euflexxa is safe and effective 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs daily medical supervision and 
management. The Plan denied your request. The Plan says the enrollee's records do not show rehabilitation 
needs are complex. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 7, 2022 to July 
14, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim was billed correctly. The Plan denied your request. The Plan says diagnosis code G93.41 is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with G93.41. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that this DRG does not meet criteria for payment. Our physician reviewer found it was noted that the mental 
status changes were more likely related to slowly progressive of a neurocognitive disorder and not a metabolic 
disorder. The enrollee was started on fluids and antibiotics. There was insufficient evidence to support the 
diagnosis code G93.41.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 7, 2022 to July 14, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot be safely discharged home and require 
rehabilitation services for your shoulder. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on December 21, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for x-ray services. You say that you were told authorization was not required for 
these services. The Plan denied your request. The Plan says out-of-network services require authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for x-ray services provided on December 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37252 and 37253 rendered on November 
21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these are add-on codes without a primary procedure. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes the 
services are add-on codes and have not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 37252 and 37253 rendered on November 21, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 pre-approve a positron emission tomography (PET) 
scan. Our reviewer says that the service is 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 a positron emission tomography (PET) scan have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) scan.  
 
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 panniculectomy (15830). 
 
You asked the Plan to pre-approve panniculectomy. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that abdominal lipectomy/panniculectomy is surgical 
removal of excessive fat and skin from the abdomen. When surgery is performed to alleviate such complicating 
factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo 
dermatitis, such surgery is considered reconstructive. 
 
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 panniculectomy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record provided is insufficient to 
determine the medical necessity of the requested service. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied. The requested service is not 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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve panniculectomy (15830).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service January 9, 
2023. 
 You asked the Plan to pay for procedure code 87481. The Plan denied your request. The Plan says payment for 
code 87481 is bundled into payment for code 87801. 
 
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 87481 
is a column II code to column I code 87801. 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 87481 billed for date of service January 9, 2023.