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

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service December 1, 
2022, to December 2, 2022.  
 
You asked the Plan to pay for procedure code 88360. 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 88360 is 6. The MAI value for this code is 3. You billed 9 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
88360 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88360 
billed for date of service December 1, 2022, to December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a controller (K0108). 
 
You asked the Plan to pre-approve a controller. The Plan denied your request. The Plan says the requested 
controller is miscoded and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a controller. 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 adequate upper body strength to manage standard power drives. 
 
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 controller have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a controller (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance urinary tract infection (UTI) panel coded as 
87481, 87500, 87511, 87640, 87653, 87798 and 87801, provided March 17, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you provided services in good faith that you 
would be reimbursed. The Plan denied your request. The Plan says this request does not meet Medicare rules 
because the testing is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The testing is not FDA approved. The testing has undergone 
registration with Molecular Diagnostic Services Program (MolDX), and there is a denied Technical 
Assessment (TA) on file. While Medicare does provide coverage for Urinary Tract Infections in certain 
populations, testing performed must meet all technical specificity requirements outlined by the MolDX 
program. Based on this information, we decided that Medicare rules for coverage of the laboratory service have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guidance urinary tract infection 
(UTI) panel coded as 87481, 87500, 87511, 87640, 87653, 87798 and 87801, provided March 17, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a K3 microprocessor knee (Kenevo) (L5828, L5845, L5848, and 
L5856). 
 
You asked the Plan to pre-approve a K3 microprocessor knee (Kenevo). You say that the requested K3 
microprocessor knee (Kenevo) is medically necessary. The Plan denied your request. The Plan says that the 
requested K3 microprocessor knee (Kenevo) 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 K3 microprocessor knee (Kenevo). 
Our reviewer says that the requested K3 microprocessor knee (Kenevo) is medically necessary. Our physician 
reviewer found the medical record (in addition to the appeal letter) more than satisfies Medicare coverage 
policy for this component, first and foremost in demonstrating this enrollee has a K3 functional level, which the 
Plan has tacitly already accepted by way of approving L5981. 
 
The Local Coverage Determination (LCD) L33787 states simply "A fluid, pneumatic, or 
electronic/microprocessor knee...is covered for beneficiaries whose functional level is 3 or above." No further 
specific documentation is required in the LCD, the Policy Article, or any of the relevant Medicare manuals 
because Medicare's policy recognizes that microprocessor knees (which include the requested Kenevo knee) 
are the basic standard of care for all community above knee amputee ambulators given that the evidence of 
their benefits and superiority to alternatives are so well proven and long standing. Less sophisticated 
technology would amount to sub-standard care and would not meet her needs. There is no doubt that original 
Medicare would cover the requested prosthesis for this K3-level beneficiary. Therefore, the requested 
microprocessor knee (L5828, L5845, L5848, L5856) is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a K3 microprocessor knee (Kenevo) have been met. Therefore, we decided that 
the Plan has to pre-approve a K3 microprocessor knee (Kenevo) (L5828, L5845, L5848, and L5856).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92950 billed for date of service January 30, 
2022. 
 
You asked the Plan to pay for procedure code 92950. You say that this service is supported as billed. 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 92950 is cardiopulmonary resuscitation (e.g., in cardiac arrest). 
 
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 92950. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the procedure report documents that the enrollee has a 
valid do-not-resuscitate order (DNR) and was pronounced dead at 8:07 PM. The emergency department record 
does not include documentation of cardiopulmonary resuscitation (CPR) and therefore this code 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 procedure code 92950 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 92950 billed for date of service January 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) billed for date of 
service February 21, 2023. 
 
You asked the Plan to pay for the special anesthesia service. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and 
not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for the special anesthesia service (99100) billed for date of service February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 8, 2022, billed 
with codes 81314, 81345, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 8, 2022, billed with codes 81314, 81345, and 81272.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided by an in-network 
provider on February 22, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a follow-up visit. 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 $35 
copayment for in-network services for the diagnosis and treatment of diseases and injuries of the eye. 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the vision care 
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 the office visit provided by an 
in-network provider on February 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36246, 36248 and 37229 billed for date of 
service November 8, 2022. 
 
You asked the Plan to pay for procedure codes 36246, 36248 and 37229. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
are 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. 
 
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 codes 36246, 36248 and 37229. Our reviewer says 
that these services are not supported as billed. Our reviewer found the records provided do not include 
sufficient documentation to validate these services. 
 
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 codes 36246, 36248 and 37229 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 36246, 36248 and 37229 billed for date of 
service November 8, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the enrollee is being scheduled for planned neurosurgery with significant co-
morbidities. An inpatient stay for greater than 2 midnights is anticipated and would be medically appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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 pre-approve nine (9) months continued use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9 months continued use of a ventilator. You say that the enrollee would like 
to continue the use of a ventilator due to the quality of care the device provides. The Plan denied your request. 
The Plan says the request for continued use of a ventilator is not medically reasonable and necessary. 
 
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 months continued use of a ventilator. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
COPD, obstructive sleep apnea (OSA), and severe obesity, and has had a home ventilator since 2017. There are 
no pulmonary function tests to assess the severity of the COPD.  The enrollee has been compliant with use of 
the home ventilator. An arterial blood gas (ABG) done July 20, 2023, as an outpatient, showed a pH of 7.39 
and a partial pressure of carbon dioxide (PaCO2) of 47. The records do not show that the patient has been tried 
on bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) as an 
outpatient.  Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP.  The plan has approved the current device 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 months continued use of a ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve nine (9) months continued use of a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2023, to March 15, 
2023, billed with codes 87481 x10 and 87798 x26. 
 
You asked the Plan to pay for the genetic testing billed. You say that please see the attached records for appeal 
and reconsideration. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. The unbundling of lab codes for PCR panel testing is not appropriate. 
 
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 
March 8, 2023, to March 15, 2023, billed with codes 87481 x10 and 87798 x26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service March 13, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 87640 is included in the payment for 
code 87641. 
 
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 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 87640. Our reviewer says that procedure 
code 87640 does not meet criteria for payment. Our reviewer found that procedure code 87641 is the more 
comprehensive procedure as Staphylococcus aureus and methicillin resistant tests are both performed. The 
provided laboratory report does not include documentation to support a distinct procedural service was 
provided. 
 
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 87640 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87640 billed for date of service March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder (K0108) and walker holder (K0108). 
 
You asked the Plan to pre-approve a walker holder. You say that the denial of these particular items does not 
make the base or any other accessories unusable. The Plan denied your request. The Plan says these items do 
not meet the coverage criteria.  

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 pre-approve a cup holder (K0108) and walker holder (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87532 and 87496 billed for date of 
service October 11, 2022. 
 
You asked the Plan to pay for procedure codes 87798, 87532 and 87496. You say that these services are not 
supported in the medical record. The Plan denied your request. The Plan says these services were necessary and 
are 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. 
 
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 codes 87798, 87532 and 87496. Our reviewer says 
that these services cannot be verified as tested. Our reviewer found there were no results or review of the 
organisms included in the medical records. 
 
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 codes 87798, 87532 and 87496 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87798, 87532 and 87496 billed for date of 
service October 11, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on March 17, 2022, to March 19, 
2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported correctly and are supported in the medical record. The Plan denied your 
request. The Plan says that this DRG is not supported as diagnosis code Z68.42 cannot be verified in the 
records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with Z68.42 (body mass index [BMI] of 45.0-49.9, 
adult). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules 
to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that this diagnosis is supported by the records provided. Our physician 
reviewer found the documentation supports that the enrollee's BMI is 48; therefore, diagnosis code Z68.42 is 
supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on March 17, 2022, to March 19, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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.