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

We decided that the Plan does not have to waive the copayment for an out-of-network walk in office visit provided on April 5, 2023.

You asked the Plan to waive the copayment for an out-of-network walk in office visit. You say that you were not at a lab on this day, you were at a walk-in clinic. The Plan denied your request. The Plan says this cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for Physician/Practitioner services and a 20% coinsurance for Medicare Part B prescription drugs.
You have a copayment of $65 for specialist services, an $1.09 (20%) for the Medicare B prescription drugs ($65 + $1.09 = $66.09).

You have been asked to pay a $65 copayment for Physician/Practitioner services and a 20% coinsurance for Medicare Part B prescription drugs for an out-of-network walk in office visit. This item/service falls within the Physician/Practitioner services and Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an out-of-network walk in office visit provided on April 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4-L5 lumbar fusion utilizing the Nuvasive AFFIX 
Interspinous Fixation System (22840, 22612). 
 
You asked the Plan to pre-approve L4-L5 lumbar fusion utilizing the Nuvasive AFFIX Interspinous Fixation 
System. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical 
value and effectiveness of the Nuvasive AFFIX Interspinous Fixation System have not been 
demonstrated in the peer-reviewed literature. 
 
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 L4-L5 lumbar fusion utilizing the 
Nuvasive AFFIX Interspinous Fixation System. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the AFFIX 
interspinous system is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L4-L5 lumbar fusion utilizing the Nuvasive AFFIX Interspinous Fixation 
System have not been met. Therefore, we decided that the Plan does not have to pre-approve L4-L5 lumbar 
fusion utilizing the Nuvasive AFFIX Interspinous Fixation System (22840, 22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28296 billed for date of service October 26, 
2022.  
 
You asked the Plan to pay for procedure code 28296. You say that the claim was partially 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 28296 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 28296 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 28296 billed for date of service October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
January 16, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this device is not covered. 

The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used only for 
peripheral artery disease. 
 
We looked at the file and Medicare rules. The record shows the enrollee received this device for a diagnosis of 
obstructive sleep apnea. Therefore, we decided that the Plan does not have to pay for the pneumatic 
compression device (E0675) provided on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 87150 billed for date of service March 7, 
2023. 
 
You asked the Plan to pay for procedure code 87150. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87150 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 87150 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -XU modifier is not supported as a separate and distinct procedural service. 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 87150 billed for date of service March 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 76937 billed for date of service October 3, 2022. 
 
You asked the Plan to pay for code 76937. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not bill this code with an appropriate primary 
procedure 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 76937 
is an add-on code and has 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 code 76937 billed for date of service October 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T8 and T10 kyphoplasty (22515 x2). 
 
You asked the Plan to pre-approve T8 and T10 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria. The compression fractures to T8 and 
T10 are chronic. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 T8 and T10 kyphoplasty. Our reviewer 
says that the enrollee does not meet criteria for coverage. Our physician reviewer found there is no trial of a 
back brace for fracture treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T8 and T10 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve T8 and T10 kyphoplasty (22515 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81314) provided on August 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 (81314) provided on August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says although there are three approved power options on this wheelchair (tilt, 
recline and elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided records document that the 
enrollee has four minus to four out of 5 right upper extremity strength and is independent with dressing, 
grooming and meal prep thus indicating they have adequate upper extremity strength and function to operate 
the wheelchair's power options with their own switches. 
 
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 connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 20, 2022, billed 
with codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81355 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 20, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 
81335, 81355 and 81408.
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 would benefit from and can tolerate an 
intensive interdisciplinary treatment program. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for inpatient rehabilitation. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot/cold pack therapy, infrared therapy, preventive 
medicine counseling, and evaluation and management (EM) services (97010, 97026, 99214, and 99401) 
provided with acupuncture treatment on September 5, 2022. 
 
You asked the Plan to pay for the services coded 97010, 97026, 99214, and 99401. You say that the claim 
should be paid since this was provided in accordance with Medicare rules. The Plan denied your request. The 
Plan says the direct acupuncture treatments were approved for payment on appeal. However, the other services 
are not covered under this benefit when provided by an acupuncturist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. We find that the Plan made payment for the services eligible for 
coverage under the acupuncture benefit. The remaining services are medical or therapy services which cannot 
be covered when provided by an acupuncturist. Based on this information, we decided that the rules for 
coverage of the acupuncture services have not been met.  Therefore, we decided that the Plan does not have to 
pay for the hot/cold pack therapy, infrared therapy, preventive medicine counseling, and evaluation and 
management (EM) services (97010, 97026, 99214, and 99401) provided with acupuncture treatment on 
September 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating system, tilt only (E1002) and center 
mount power elevating leg rest/platform (E1012). 
 
You asked the Plan to pre-approve a power seating system, tilt only and center mount power elevating leg 
rest/platform. You say that the recommended device provides the enrollee with the features they require as a 
full-time user. You also say that a standard power wheelchair will not meet the enrollee's needs. The Plan 
denied your request. The Plan says the request for power elevating leg rests and tilt-in-space, does not meet the 
Medicare criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that a power seating system  tilt only, recline only, or 
combination tilt and recline  with or without power elevating leg rests will be covered if criteria listed in the 
Medicare rules section of this letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power seating system, tilt only and 
center mount power elevating leg rest/platform. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not 
have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means 
of managing power drive. Our reviewer found that the enrollee does have chronic edema of her lower 
extremities. Our physician reviewer also found that the physical therapy evaluation states the enrollee has anti-
gravity strength and therefore can elevate their legs without a power leg rest. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power seating system, tilt only and center mount power elevating leg 
rest/platform have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
seating system, tilt only (E1002) and center mount power elevating leg rest/platform (E1012).
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 you need rehabilitation to be independent. The Plan denied your request. The Plan says your condition does not meet the requirements. 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 your 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87491 billed for date of service October 26, 
2022. 
 
You asked the Plan to pay for procedure code 87491. You say that this service was reported appropriately. The 
Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. 
 
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 code 87491. Our reviewer says that this service is 
not supported in the medical record. Our reviewer found the laboratory report does not include documentation 
of Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe 
technique. This procedure was not found in medical record submitted, and therefore cannot be verified as 
performed. 
 
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 code 87491 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87491 billed for date of service October 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93308 and 93325 billed for date of service 
March 2, 2023.  
 
You asked the Plan to pay for procedure codes 93308 and 93325. You say that you disagree with the Plan's 
denial. 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 93308 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. 
 
The MUE for CPT code 93325 is 2. The MAI value for this code is 3. You billed 3 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 93308 and 93325 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 93308 and 
93325 billed for date of service March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81292, 81294, 81295, 81297, 81298, and 
81317 for date of service November 22, 2022. 
 
You asked the Plan to pay for procedure codes 81292, 81294, 81295, 81297, 81298, and 81317. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
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 find that CPT codes 81292, 81295, 81298, and 81317 are not supported in the medical record. Specifically, 
the documentation shows that a comprehensive panel was performed. There is a more appropriate code to be 
billed for these services. 
 
In this case, we have confirmed that code 81294 is a column II code to column I code 81292. We have 
confirmed that code 81297 is a column II code to column I code 81295. This claim has not been billed with an 
appropriate modifier to bypass the edit. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 81292, 81294, 
81295, 81297, 81298, and 81317 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 81292, 81294, 81295, 81297, 81298, and 81317 for date of service November 22, 2022.