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

 
We decided that the Plan does not have to pre-approve a group 4 standard power wheelchair (K0884). 
 
You asked the Plan to pre-approve a group 4 standard power wheelchair. You say that your health is in serious 
jeopardy by not having the wheelchair. The Plan denied your request. The Plan says the power wheelchair 
requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that group 4 PWCs have added capabilities that are 
not needed for use in the home, and will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 4 standard power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 4 standard power wheelchair (K0884).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed (E0303). 
 You asked the Plan to pre-approve a heavy duty, extra wide hospital bed. You say that you must be turned over 
multiple times a day and need a bed big enough to accommodate this. The Plan denied your request. The Plan 
says you do not meet criteria for this type of bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The provided records show that you are less than 350 pounds. Based 
on this information, we decided that Medicare rules for coverage of a heavy duty, extra wide hospital bed have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, extra wide 
hospital bed (E0303).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says the requested drug is not being furnished by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage.  Therefore, we decided that 
the Plan does not have to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99214 & 80305 provided on August 23, 
2022. 
 
You asked the Plan to pay for procedure codes 99214 & 80305. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 CPT codes 99214 & 80305 are not supported in the medical record. Specifically, code 99214 is 
included in code 96365 and is not separately payable. Lab results were not included for review for code 80305. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99214 & 80305 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99214 & 
80305 provided on August 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0207 billed for date of service May 9, 2021. 
 
You asked the Plan to pay for procedure code S0207. You say that the ambulance company refuses to correct 
the coding. 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 S0207 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0207 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S0207 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0207 billed for date of service May 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 19, 2022, billed with 
codes 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 0031U, 
0032U, 0033U, 81407, 81406, 81238, and 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have provided the medical records as 
well as a letter explaining the Place of Service code billed. 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 
July 19, 2022, billed with codes 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81355, 81335, 81401, 0031U, 0032U, 0033U, 81407, 81406, 81238, and 81225.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on July 12, 2022, to July 15, 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 the 
claim is billed correctly. The Plan denied your request. The Plan says that the principal diagnosis A41.9 is not 
supported. 
 
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 A41.9 - Sepsis, unspecified organism. 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 physician reviewer found the clinical documentation supports the use of diagnosis code A41.9 (Sepsis, 
unspecified organism). Sepsis is the body's response to an infection and is a potentially life-threatening medical 
emergency. Sepsis results from infection which triggers a chain reaction in the body. Infections that lead to 
sepsis often start in the lung, as in this case. Without timely treatment, sepsis can lead to tissue damage, organ 
failure, and death. 
 
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 July 12, 2022, to July 15, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99222) provided on June 17, 2022. 
 
You asked the Plan to pay for initial hospital care (99222). You say that procedure code 99222 is correct for 
this date of service. You say that the claim should be reviewed and considered for payment. The Plan denied 
your request. The Plan says the medical records submitted do not support a comprehensive history. 
 
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 99222 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 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, 50 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 initial hospital care (99222). Our reviewer says that the 
documentation does not support procedure code 99222. Our reviewer found this initial hospital care evaluation 
and management code requires a comprehensive history, a comprehensive examination and medical decision 
making of moderate complexity. In this case, the medical records submitted do not support a comprehensive 
history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99222) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99222) provided on June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 9, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on November 9, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. 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 procedure code 99100 billed for date of service November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracorporeal shock wave involving musculoskeletal 
system (0101T) provided from September 15, 2022, through December 12, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is a more appropriate code for this procedure.  
 
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 0101T is extracorporeal shock wave involving 
musculoskeletal system, not otherwise specified. 
 
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 found the provided records report the enrollee was treated with low-energy shock wave treatments for erectile dysfunction September 15, 2022, 
through December 12, 2022. Code 0101T is used for high energy extracorporeal shock wave therapy. Code 
0019T is used for low energy shock wave therapy.  
 
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 extracorporeal shock wave involving musculoskeletal system (0101T) provided from 
September 15, 2022, through December 12, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 81479. We decided that the Plan does not have to pay 
for procedure code 81291-GZ.  
 
You asked the Plan to pay for procedure codes 81479 and 81291-GZ billed for date of service December 15, 
2022. You say that these services are supported in the medical records. The Plan says that code 81479 was not 
reported with the necessary unique identifier and code 81291 was reported with modifier GZ which is not 
payable. 
 
We decided that the Plan has to pay for procedure code 81479.  
 
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 shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of procedure code 81479 
have been met. Therefore, we decided that the Plan has to pay for procedure code 81479.  
 
We also decided that the Plan does not have to pay for procedure code 81291-GZ. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that A/B MACs shall 
automatically deny claim line(s) items submitted with a GZ modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 81291-GZ have not been met. Specifically, the records provided show that this 
code was reported with the GZ modifier. Therefore, we decided that the Plan does not have to pay for 
procedure code 81291-GZ. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. 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 January 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrotomy, with synovectomy (27335) provided on 
August 15, 2022. 
 
You asked the Plan to pay for the arthrotomy, with synovectomy (27335). You say that the claim should be 
processed for payment. The Plan denied your request. The Plan says procedure code 27335 is considered 
inclusive to procedure code 27447. 
 
 
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 27335 is a column II code to column I code 27447; however, 27335 
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 the arthrotomy, with synovectomy (27335). Our reviewer 
says that procedure code 27335 is not separately reportable. Our reviewer found that the arthrotomy is included 
in the more extensive procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the arthrotomy, with synovectomy (27335) have not been met. Therefore, we 
decided that the Plan does not have to pay for the arthrotomy, with synovectomy (27335) provided on August 
15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two bedside drainage bags (A4357) and two leg bags 
(A4358). 
 
You asked the Plan to pre-approve the bedside drainage bags and leg bags. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the request exceeds the allowed amount for 
these items. 
 
The Plan must follow Medicare rules. Medicare rules say that two urinary drainage bags are allowed a month. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the bedside drainage bags and leg bags have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two bedside drainage bags (A4357) and two leg bags (A4358).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the admission to an IRF is not medically 
necessary. 
 
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 you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical 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 you 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonpneumatic compression controller (K1024) and 
compression garment (K1033). 
 
You asked the Plan to pre-approve a nonpneumatic compression controller and compression garment . You say 
that the items are medically necessary. The Plan denied your request. The Plan says the items 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 a nonpneumatic compression controller 
and compression garment. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee's records show that she was evaluated for 
a trial of conservative therapy, but not that she completed a four-week trial of conservative treatment or the results of that trial of treatment. 
 
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 nonpneumatic compression controller and compression garment have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a nonpneumatic compression controller 
(K1024) and compression garment (K1033).