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

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and 2 or more power seating system motors (E2311), a harness 
(E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you have a medical history including, 
but not limited to paraplegia, diabetes and chronic back issues. You require maximal assistance for transfers 
and require support to maintain sitting balance. You require the K0861 base & all recommended components to 
meet your mobility, medical & functional needs in your home. The Plan denied your request. The Plan says  a 
power seat elevation feature is non-covered because it is not primarily medical in nature. The expandable 
controller, the harness and electronic accessory are requested to control power tilt, recline and power elevating 
leg rests through the joystick.  Although there are three requested power options (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found you have a diagnosis of 
paraplegia and require a power wheelchair for mobility. The requested power seat elevation feature is 
statutorily non-covered as it serves no primary medical purpose. Provided records document that you have 4/5 
to 5/5 bilateral upper extremity strength with upper extremity range of motion rated as within functional limits 
thus indicating you have adequate upper extremity strength and function to operate the wheelchair's power 
options with their own switches.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system (E2300), an electronic connection between 
wheelchair controller and 2 or more power seating system motors (E2311), a harness (E2313) and an 
expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraoperative neurophysiology monitoring (IONM) 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted procedure code reflects 
the presence of the monitoring physician in or during the procedure. The monitoring physician is to be distinct 
from the surgeon. There was no indication that a separate physician would be providing the IONM services in the operating room in real time, based on the records provided. The IONM is not the standard of care for the 
approved procedures and is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intraoperative neurophysiology monitoring (IONM)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 provided on December 29, 2022. 
 
You asked the Plan to pay for procedure code A4557. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that code A4557 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have 
to pay for procedure code A4557 provided on December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, 87641, and 87150 
billed for date of service June 23, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, 87798, 87641, and 87150. You say that payment 
in full should be made.  The Plan denied your request. The Plan says payment for codes 87481, 87653, 87798, 
87641, and 87150 is bundled into payment for codes 87801 and 87500. 
 
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 codes 87481, 87653, 87798, 87641, and 87150 are column II codes to 
column I codes 87801 and 87500. This claim has not been billed with appropriate modifiers to bypass the edits. 
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 codes 87481, 87653, 87798, 87641, and 87150 billed for date of service 
June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and enhanced 
seating (K0108).  
 
You asked the Plan to pre-approve the items. You say that it is your determination that it is medically necessary 
for the enrollee to have the prescribed options, accessories, and postural seating components on their powered 
mobility device. The Plan denied your request. The Plan says a seat elevator does not serve a primary medical 
purpose and is statutorily non-covered. The Plan also says that code K0108 cannot be used for any part of the 
expandable controller and harness.  
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the power seat elevation system is considered not medically necessary and a convenience. 
K0108 is not a medically necessary code. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation system (E2300) and enhanced seating (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a non-invasive ventilator (NIV) device 
(E0466) for nine (9) months. 
 
You asked the Plan to pre-approve continued use of a NIV for 9 months. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the request for continued use 
of a NIV is not medically reasonable and necessary. The documentation indicates that this device is being used 
solely for iVAPS, and thus it is being used in a mode that Medicare considers a respiratory assist device. 
 
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 continued use of a NIV for 9 months. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of asthma, obstructive sleep apnea, left diaphragm paralysis, and HFpEF. The enrollee has had 
multiple hospitalizations for hypercarbic respiratory failure. In 2017, the enrollee was hospitalized with 
pneumonia and suffered a cardiopulmonary arrest. The enrollee was intubated and eventually had a 
tracheostomy and prolonged recovery. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. Some records mention a diagnosis of COPD. However, undated pulmonary function testing results 
indicate an FEV1 of 61% of predicted, FEV1/FVC ratio of 82%, and total lung capacity of 68% of predicted. 
These results are more indicative of moderate restrictive lung disease.  The enrollee had been on BiPAP for 
obstructive sleep apnea but was provided with a ventilator in April 2021.  A compliance report covering March 
to April of 2023, shows excellent compliance with use of the device. It appears this enrollee's respiratory 
support needs could be met with BiPAP with AVAPS during sleep. The records do not show that this has been 
tried and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. The current device should be approved for an additional 3 months to allow time for 
transition to BiPAP with AVAPS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a NIV for 9 months have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued use of a non-invasive ventilator (NIV) device (E0466) for 
nine (9) months.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on July 25, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on July 25, 2022.  The Plan denied your request. The Plan says the medical records do not 
support the billing of code 99223 provided on July 25, 2022.  
 
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 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 99223. Our reviewer says that the medical 
records do not support the billing of code 99223 provided on July 25, 2022.  Our reviewer found for the date of 
service July 25, 2022; code 99223 was not supported. Specifically, there was no comprehensive history or 
medical decision making of high complexity. 
 
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 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950). 
 
You asked the Plan to pre-approve a core buildup. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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, the requested items or services are not 
among those covered under this benefit.    Therefore, we decided that the Plan does not have to pre-approve a 
core buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99360 billed for date of service October 26, 
2022.  

You asked the Plan to pay for procedure code 99360. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 99360 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code 99360 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99360 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99360 billed for date of service October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) for toot #25. 
 
You asked the Plan to pre-approve the dental service. You say that the requested dental service is medically 
necessary. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan approved a retainer crown for tooth #23 on May 16, 2023; therefore, the enrollee's benefit for 
the requested item or service was exhausted on the date of approval of May 16, 2023. Therefore, we decided 
that the Plan does not have to pre-approve a retainer crown (D6740) for toot #25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0028 billed for date of service February 1, 
2023. 
 
You asked the Plan to pay for procedure code S0028. You say that this should be paid.  The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S0028 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0028 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0028 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0028 billed for date of service February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting.  Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service September 
21, 2022. 
 
You asked the Plan to pay for procedure code 87798. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87798 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87798 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -XU modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met.  Therefore, we decided that the Plan does not 
have to pay for procedure code 87798 billed for date of service September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided on December 24, 2022, 
through December 26, 2022, and December 28, 2022, through December 29, 2022. 
 
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says these services have been partially approved.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our physician 
reviewer found the criteria for inpatient psychiatric care are not met for December 24, 2022, through December 
26, 2022, and December 28, 2022, through December 29, 2022. This enrollee was not shown to be a danger to 
themselves or others, delusions, auditory or visual hallucinations noted. The enrollee was 
cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient mental health care provided on December 24, 2022, through December 
26, 2022, and December 28, 2022, through December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81272, 81314, 81345) provided on 
November 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting.  Therefore, we decided that 
the Plan does not have to pay for the laboratory services (81272, 81314, 81345) provided on November 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 
15, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87481 is bundled into 
payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87481 
is a column II code to column I code 87801. 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 87481 billed for date of service December 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair (A9270) for use with a seat lift mechanism. 
 
You asked the Plan to pre-approve a chair. You say that you do not understand how you can have the 
mechanism without having the chair as the lift mechanism is inside of it. Not having this chair/mechanism 
makes it incredibly hard to try to get up and not having it will impact my quality of life. The Plan denied your 
request. The Plan says Medicare does not cover the chair/furniture for use with a seat lift mechanism. 
 
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 chair (A9270) for use with a seat lift mechanism.