Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), 
electronic connector (E2311), cup holder (K0108), and footplate extensions (K0108 x2). 
 
You asked the Plan to pre-approve an expandable controller, harness, electronic connector, cup holder, and 
footplate extensions. 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 an expandable controller, harness, 
electronic connector, cup holder, and footplate extensions. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found provided 
records document that the enrollee has 5/5 bilateral upper extremity strength and is independent with meal 
prep, grooming and feeding thus indicating she has adequate upper extremity strength and function to operate 
the wheelchair's power options with their own switches. The requested cup holder is statutorily non-covered as 
it serves no primary medical purpose. Provided medical records from the treating provider in this case do not 
document an issue with the enrollee's feet that requires the footplate extension. 
 
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 expandable controller, harness, electronic connector, cup holder, and 
footplate extensions have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller (E2377), harness (E2313), electronic connector (E2311), cup holder (K0108), and 
footplate extensions (K0108 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for approval of a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the enrollee was recently hospitalized with acute hypoxic respiratory failure. Venous blood gases were consistent 
with acute on chronic CO2 retention, but there is no arterial blood gas (ABG) done while stable to document 
chronic CO2 retention. A diagnosis of chronic obstructive pulmonary disease (COPD) is presumed, but there 
are no pulmonary function tests and no emphysema on chest computed tomography (CT) scan. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. The enrollee does have heart failure with 
preserved ejection fraction (HFpEF) and pulmonary hypertension with right heart failure. The enrollee 
improved in the hospital on bilevel positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS). The enrollee may benefit from BiPAP with AVAPS during sleep as an outpatient.  This has 
not been tried as an outpatient.  Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 6, 2022, billed with 
evaluation and management (EM) code 99204-FS-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the level of care is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
In this case, the CPT Code Manual definition of code 99204-FS-25 is office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter. 
 
We asked our physician to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation is insufficient to 
support procedure code 99204-FS-25. In this case, the documentation does not support medical decision 
making of moderate complexity. The case file does not contain review of laboratory testing, and a moderate 
risk of morbidity from additional testing or treatment is not documented. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 6, 2022, billed with evaluation and 
management (EM) code 99204-FS-25.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 75726 and 75774 rendered on March 18, 2023. 
 
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 that the denied codes are inclusive to other codes. 
 
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 
the denied codes is: 
 
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports coverage 
of the imaging codes in question. Diagnostic angiography is separately billable and not bundled into the 
embolization code. There is documentation that two instances of visceral angiography was performed with 
satisfactory description of findings to justify use and coverage of code 75726x2 and, similarly, documentation 
that the catheter was repositioned for additional angiography after basic was performed with satisfactory 
description of findings to justify use and coverage of code 75774. These services are distinct from any 
angiography performed in the context of the actual embolization procedure. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 75726 and 75774 rendered on March 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service 
September 29, 2022. 
 
You asked the Plan to pay for procedure code 81345-GZ. You say that the testing was deemed medically 
necessary. The Plan denied your request. The Plan says payment for code 81345-GZ is bundled into payment 
for code 0089U. 
 
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 81345 is a column II code to column I code 0089U. Code 81345 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 81345-
GZ billed for date of service September 29, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 11, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says with the 
information we have, we cannot determine how the member came to the servicing provider, whether the billed 
services were actually performed, or that the services were medically necessary.  
 
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 psychotherapy have been met. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and arthrocentesis (20600) provided 
on February 8, 2023. 
 
You asked the Plan to pay for the office visit (99204) and arthrocentesis (20600). The Plan denied your request. 
The Plan says procedure codes 99204 and 20600 are not supported by the medical records submitted. 
  
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. The CPT Code Manual definition of code 20600 is arthrocentesis, aspiration 
and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance. 
 
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 office visit (99204) and arthrocentesis (20600). Our 
reviewer says that the record does not support the codes reported. Our reviewer found that the records 
document low level medical decision making. In addition, the procedure performed was a trigger point 
injection to treat trigger finger, not a joint injection. There are more appropriate codes for the services 
documented. 
 
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 office visit (99204) and arthrocentesis (20600) have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit (99204) and arthrocentesis (20600) 
provided on February 8, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 30, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) month use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve 9-month use of a ventilator. You say that it is medically necessary for you to 
have the home ventilator. Without the ventilator and oxygen, you will die. The Plan denied your request. The 
Plan says the records do not show that you have been compliant with using this device every day for at least 
four hours. You do not meet criteria for approval of continued use of a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 

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 9-month use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have 
COPD/asthma and chronic thromboembolic pulmonary hypertension. You were prescribed a home ventilator in 
March 2023, following a hospitalization. An arterial blood gas (ABG) during that hospitalization showed acute 
on chronic hypercarbic respiratory failure. You are obese with a body mass index (BMI) of 36.6.  Pulmonary 
function testing on April 21, 2023, showed a forced expiratory volume (FEV1) of 51% of predicted with an 
obstructive pattern. Your COPD does not appear to be severe enough, by pulmonary function testing, to cause 
significant chronic carbon dioxide (CO2) retention. Therefore, obesity hypoventilation syndrome may be 
present.  The records do not show that you have tried and failed bilevel positive airway pressure (BiPAP) with 
average volume assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a 
home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that can be 
provided with BiPAP. The plan has approved the ventilator for 3 months, which allows time for transition to 
BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9-month use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) month use of a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798-XU billed for date of service January 
13, 2023. 
 
You asked the Plan to pay for procedure code 87798-XU. You say that medical records were provided. The 
Plan denied your request. The Plan says payment for code 87798-XU 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.  
 
The file shows that a urinary tract infection panel was provided. In this case, we have confirmed that code 
87798 is a column II code to column I code 87801. Code 87798 was billed with an XU modifier. The records 
do not show that this test was separate and distinct from the main 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 87798-XU billed for date of service January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telomerase reverse transcriptase (TERT) (eg, thyroid 
carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) (81345) 
provided on October 4, 2022.  
 
You asked the Plan to pay for the laboratory service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service is not covered by the Health Plan or Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. The Z-code (ZBBIA) is 
not covered by Medicare per the Palmetto GBA DEX Registry. Therefore, we decided that the Plan does not 
have to pay for the telomerase reverse transcriptase (TERT) (eg, thyroid carcinoma, glioblastoma multiforme) 
gene analysis, targeted sequence analysis (eg, promoter region) (81345) provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for audiology services (92557, 92567, 92700) provided on 
December 16, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for audiology services. You say that you believe you should be considered in-
network. The Plan denied your request. The Plan says this was not authorized. 
 
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 audiology services (92557, 92567, 92700) 
provided on December 16, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on April 9, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the facility is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on April 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm or disorder, 51 or greater genes (81455) provided March 15, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the molecular testing was requested directly 
from the treating physician who makes the professional determination of diagnosis and medical necessity to 
successfully treat the enrollee. The Plan denied your request. The Plan says screening genetic testing is not a 
covered service under Medicare.  
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of monoclonal gammopathy. There is no personal history of cancer.  
Screening genetic testing is not a covered service under Medicare. The review has determined that the 
items/services at issue in this case is not 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm or 
disorder, 51 or greater genes (81455) provided March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75572-26 billed for date of service February 
10, 2023. 
 You asked the Plan to pay for procedure code 75572-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 75572-26 is bundled into payment for 
code 75574. 
 
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 
75572-26 is a column II code to column I code 75574. 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 75572-26 billed for date of service 
February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on December 28, 2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on December 28, 2022.