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

 
We decided that the Plan does not have to pay for the services provided on April 25, 2023. 
 
You asked the Plan to pay for the services. 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 the place of service (POS) code to be used by the 
physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-
face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which 
case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face 
service takes place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the inpatient POS code. The records show that the enrollee was under observation when the services were provided, and not admitted as an 
inpatient. Therefore, we decided that the Plan does not have to pay for the services provided on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1852) and suspension sleeve (L2397) 
provided June 19, 2023. 
 
You asked the Plan to pay for the orthosis. You say that you have attached the supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says under Medicare guidelines, your 
request 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 pay for the orthosis. 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 knee pain related to osteoarthritis. A request for a knee orthosis L1852 and 
suspension sleeve L2397 was made. However, the provided documentation did not clearly describe the enrollee 
with knee instability or with plans for surgery or clinical scenario where a knee orthosis would be warranted, 
nor was there a documented plan for knee bracing or why it was ordered in the encounter note. Therefore, 
without sufficient support made for this request, the patient does not meet LCD criteria for the knee orthosis 
and sleeve. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis (L1852) and suspension sleeve (L2397) provided June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450-XU rendered on May 24, 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 Current Procedural Terminology (CPT) code 64450-XU, LT (1 Unit) remains 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 64450 is "Injection(s), anesthetic agent(s) and/or steroid; 
other peripheral nerve or branch." 
 
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 not supported by the medical records. Our reviewer found that the medical record does not 
include sufficient documentation to support injection was requested by operating physician and is for post 
operate pain management. Therefore, a separate procedure from anesthesia service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 64450-XU rendered on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on March 29, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that you recommend this procedure to address pain 
and restore function. The Plan denied your request. The Plan says the request 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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Intracept procedure is considered experimental/investigational and is not medically 
necessary for the treatment of chronic low back pain. 
 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80053, 84484) provided on April 19, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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. 
 
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 use of codes 80053 
and 84484 is not supported by the records provided. Our reviewer found that the record does not contain results 
showing that these tests were 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (80053, 84484) provided on April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the F2 (prothrombin, coagulation factor II) (eg, 
hereditary hypercoagulability) gene analysis, 20210G>A variant (81240). 
 
You asked the Plan to pre-approve the F2 gene analysis, 20210G>A variant. You say that this testing is 
medically necessary. The Plan denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the F2 and F5 genetic tests are not considered to 
be clinically efficacious. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the F2 gene analysis, 20210G>A variant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) 
gene analysis, 20210G>A variant (81240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fully proportional handlebar with rubber handles and 
configurable thumb throttles, joystick cut out tray, and self-leveling cup holder. 
 
You asked the Plan to pre-approve a fully proportional handlebar with rubber handles and configurable thumb 
throttles, joystick cut out tray, and self-leveling cup holder. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. The requested 
items are considered upgraded or deluxe items. These items are not covered. Therefore, we decided that the 
Plan does not have to pre-approve a fully proportional handlebar with rubber handles and configurable thumb 
throttles, joystick cut out tray, and self-leveling cup holder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral imaging (D0230) and a mandibular 
partial denture (D5226) provided on May 16, 2023, to June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for D0230 was exhausted on date of service February 16, 2023, and May 16, 2023. Your annual dental allowance amount was exhausted on June 8, 2023, prior to D5226 being processed. The 
remaining dental services were processed with a 50% coinsurance. Therefore, we decided that the Plan does 
not have to pay for additional intraoral imaging (D0230) and a mandibular partial denture (D5226) provided on 
May 16, 2023, to June 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
11, 2023. 
 
You asked the Plan to pay for the ED services. You say that a Medicare enrollment letter was submitted. The 
Plan denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. The records do include a letter permitting the facility to be temporarily 
Medicare certified as a hospital. However, this was for services provided during the Public Health Emergency, 
which ended on May 11, 2023.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on June 11, 
2023.
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 enrollee has medical needs that make 
an LTACH admission the safest discharge plan and most appropriate level of care. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 has ongoing acute medical issues and still requires acute care 
services. 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 they are not currently receiving but that would 
be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76881 rendered on January 30, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 76881 is "Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time 
with image documentation." 
 
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 enrollee had a diagnostic right 
knee ultrasound on January 30, 2023. A review of the chart showed extensive documentation and report as well 
as hardcopy images of the right knee ultrasound done on 1/30/23. 
 
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 76881 rendered on January 30, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid. 
 
You asked the Plan to pre-approve Synthroid. You say that the enrollee has a long history of hypothyroidism 
and has requires thyroid hormone replacement. You say that you have tried several times with generic 
levothyroxine, but the enrollee has had intolerable side effects each time including palpitations, 
lightheadedness, and volatile thyroid hormone readings. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage.  
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 Synthroid.  
 
Benefits for Synthroid 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on April 3, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the services were patient specific, and physician 
directed. The Plan denied your request. The Plan says the billed services are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
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 96521 is refilling and maintenance 
of portable pump. We find that code 96521 is not supported. The records do not document the refilling and 
maintenance of a portable pump. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the Outpatient Intravenous Insulin 
Therapy (OIVIT) services provided on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Vacuum Assisted Socket System (VASS) (L5781). 
 
You asked the Plan to pre-approve a Vacuum Assisted Socket System (VASS). You say that the item is 
medically necessary. The Plan denied your request. The Plan says that the item is 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 pre-approve a Vacuum Assisted Socket System 
(VASS). Our reviewer says that the requested item is considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical records corroborate the need for this item. 
 
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 Vacuum Assisted Socket System (VASS) have been met. Therefore, we 
decided that the Plan has to pre-approve a Vacuum Assisted Socket System (VASS) (L5781).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code B9002 billed for date of service June 11, 
2023. 
 
You asked the Plan to pay for the billed service. You say that payment is allowed in this place of service. The 
Plan denied your request. The Plan says additional rental payments are not allowed. 
 
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 B9002 is enteral nutrition infusion pump, any type. We 
find that CPT code B9002 is not supported. The documentation in the case file shows that 15 months of 
payment have already been paid by the Plan. Based on this information, we decided that Medicare rules for 
coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code B9002 billed for date of service June 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve respiratory pathogen panel testing provided on  
March 27, 2023. 
 
You asked the Plan to pre-approve respiratory pathogen panel testing. You say that the respiratory pathogen 
panel testing was medically necessary. The Plan denied your request. The Plan says the respiratory pathogen 
panel testing does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare 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 pre-approve respiratory pathogen panel testing. Our 
reviewer says that the requested respiratory pathogen panel testing is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee presented with symptoms of sinusitis and 
was diagnosed with chronic sinusitis. A nasopharyngeal swab was used to do DNA/RNA respiratory pathogen 
panel test. Doxycycline and Flonase were prescribed. However, more than 5 pathogens were ordered for this 
panel, therefore the testing does not meet the Medicare LCD coverage criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of respiratory pathogen panel testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve respiratory pathogen panel testing provided on March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve a SPRINT peripheral nerve stimulator. 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 a SPRINT peripheral nerve stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this procedure would be considered experimental/investigational for 
sacroiliitis. Therefore, the request is deemed 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 a SPRINT peripheral nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator.