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

 
We decided that the Plan does not have to pre-approve the Barostim Neo device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this has not been shown to be safe and effective. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollees clinical 
management.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 8, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on February 8, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on December 12, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not payable for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient service (99223) provided on December 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was not in 
an inpatient status for this date of service. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit".  
We find that CPT code 99223 is not supported in the medical record. Specifically, the records do not show that 
the enrollee was under inpatient status on the date of service in question. It is inappropriate to bill an inpatient 
code under observation status. 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 inpatient service 
(99223) provided on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 for date of service January 27, 2023. 
 
You asked the Plan to pay for procedure code 99232. 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
 
 We find that CPT code 99232 is not supported in the medical record. Specifically, this service was billed with 
diagnosis codes E11.621 (Type 2 diabetes mellitus with foot ulcer) and E08.621 (Diabetes mellitus due to 
underlying condition with foot ulcer). These two diagnosis codes should not be billed together. This code is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure code 
99232 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99232 
for date of service January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99305) provided on December 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99305 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit". 
 
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 code 99305 is 
not supported by the records provided. Our reviewer found that the medical records submitted do not support a 
comprehensive history and a comprehensive examination. 
 
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 services (99305) provided on December 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code L1812 billed for date of service February 27, 
2023.  
 You asked the Plan to pay for procedure code L1812. You say that the items at issue were a medical necessity 
for the enrollee. 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 L1812 is 2. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code L1812 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code L1812 billed for date of service February 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria as the records show that the enrollee 
quit smoking 40 years ago. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that that the enrollee quit smoking 40 years ago. The 
criteria requirement is that the enrollee has quit smoking less than 15 years ago.. Therefore, we decided that the 
Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no report about failure to improve after six or more weeks of treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the enrollee's prior 
MRI of the lumbar spine in 2018 revealed a history of stenosis at L4-5. Physical therapy was noted to have 
helped this problem in the past, but there is no detail as to timing or duration. The requested scan could be 
indicated if the enrollee had completed a six week course of physical therapy within the past six months. 
However, there is a lack of details on physical therapy. Absent any red flags, the medical necessity of the 
requested MRI has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound for abdominal aortic aneurysm (AAA) 
provided on December 12, 2022. 
 
You asked the Plan to pay for the ultrasound. The Plan denied your request. The Plan says the coverage criteria 
are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing for AAA screenings, the 
appropriate ICD-10 codes should be billed.  
 We looked at the file and Medicare rules. In this case, the claim was only billed with diagnosis code Z13.6. 
According to A55071, a second diagnosis code is required when billing an ultrasound for AAA. An appropriate 
second diagnosis code was not billed in this case. Based on this information, we decided that Medicare rules 
for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultrasound for abdominal aortic aneurysm (AAA) provided on December 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 31, 2022, to 
February 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the plan has not told you what 
the issue is with your claim. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 31, 2022, to 
February 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97610 billed for date of service February 9, 
2023.  
 You asked the Plan to pay for procedure code 97610. You say that the claim was billed correctly and should be 
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 97610 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 97610 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 97610 billed for date of service February 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF test rendered on December 22, 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 this test is not approved or cleared for the enrollee's condition. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation provided indicating that the enrollee has either recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer. The review has determined that the enrollee does not 
meet the criteria for this testing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus xF test rendered on December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 17, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a serious life-threatening 
constellation of acute medical problems that have left them at a functional status below their baseline. You also 
say that the requested IRF admission is necessary to optimize the enrollee's level of functioning prior to 
returning home. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
Medicare guidelines for IRF services.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a positioning cushion/pillow/wedge (E0190) and 
unlisted special service, procedure or report (99199) purchased January 23, 2023. 
 
You asked the Plan to reimburse you for a positioning pillow. You say that you had called to see if you could 
get equipment to use after eye surgery and was told you were entitled to get the medical equipment that you 
needed. The Plan denied your request. The Plan says this item is no considered DME and is 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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to reimburse you for a positioning cushion/pillow/wedge (E0190) and 
unlisted special service, procedure or report (99199) purchased January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service July 20, 
2022. 
 You asked the Plan to pay for procedure code(s) 88381. You say that this service was medically necessary and 
was reported appropriately. 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) 88381. 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) 88381. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support the rationale for repeating this invasive imaging 
study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time 
cardiac catheterization would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).