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

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691) provided 
on May 16, 2023. 
 
You asked the Plan to pay for the UV light therapy system. You say that the item was medically necessary. The 
Plan denied your request. The Plan says there is no indication the enrollee has psoriasis in the medical records 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that UV cabinets are covered for selected patients 
with generalized intractable psoriasis. Using appropriate consultation, the MAC should determine whether 
medical and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of 
a hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UV light therapy system have not been met. Therefore, we decided that the Plan does not have 
to pay for the ultraviolet (UV) light therapy system (E0691) provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (64450), supplies (99070), and utlrasonic 
guidance (76942) provided on May 04, 2023, to June 08, 2023. 
 
You asked the Plan to pay for the anesthesia (64450), supplies (99070), and utlrasonic guidance (76942). You 
say that the services were medically necessary. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the anesthesia (64450), 
supplies (99070), and utlrasonic guidance (76942) provided on May 04, 2023, to June 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23020 rendered on July 6, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 23020 is considered inclusive to procedure code 23472. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
documentation does not support CPT 23020: capsular contracture release as a separate and distinct procedure 
from CPT 23472: arthroplasty, glenohumeral joint, total shoulder (glenoid and proximal humeral replacement 
(e.g., total shoulder)). The enrollee was being treated for a contracture of the right shoulder. He underwent a 
right reverse total shoulder arthroplasty, anterior and posterior capsular contracture release, and single muscle transfer of the long head of the biceps to the pectoralis major on 7/6/23. The procedure details cite the anterior 
and posterior capsule tissue was assessed and appeared to be contracted. The anterior capsule was released 
from the 1 down to the 6 oclock position and then the posterior capsule from the 9 down to the 6 oclock 
position. Then the humeral head was easily able to be dislocated. The anterior and posterior capsular releases 
were performed to allow for the dislocation of the humeral head, which is needed to complete the main 
procedure of reverse total shoulder arthroplasty.  
 
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 procedure code 23020 rendered on July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition supplies billed with codes B4199, 
B4220, and B4224 for date of service May 20, 2023, to May 25, 2023. 
 
You asked the Plan to pay for the parenteral nutrition supplies billed with codes B4199, B4220, and B4224. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid physician order for the supplies provided in this case. The records 
submitted do not include a valid physician order with the billed date of service. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the parenteral nutrition supplies billed with codes B4199, B4220, and B4224 for 
date of service May 20, 2023, to May 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99483 billed for date of service May 17, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the service was medically necessary. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that certain diagnosis codes have an Excludes1 note which lists 
other diagnosis codes with which they cannot be reported.  In this case, we have confirmed that diagnosis code group G30 has an Excludes1 note in relation to diagnosis 
code group F03. This means that diagnosis codes G30.8 and F03.B2 cannot be reported together. Based on this 
information, we decided that the Medicare billing rules for the billed service have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99483 billed for date of service May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 29, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed test is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The billed testing in this case is not covered under DEX Diagnostics 
Exchange. 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 genetic testing provided on August 29, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on May 
15, 2023, through June 7, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on May 15, 2023, through June 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 27, 2023, to 
March 6, 2023, 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 was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of E43 (Unspecified severe 
protein-calorie malnutrition). 
 
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 E43 defined as unspecified severe protein-calorie 
malnutrition. 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 that the documentation did not reveal sufficient support 
for the secondary diagnosis code, E43 (Unspecified severe protein-calorie malnutrition).   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 27, 2023, to March 6, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99213 performed on date of service July 26, 2023. 
 
You asked the Plan to pay for 99213. You say that 99213 should be paid as billed because the diagnoses 
assigned were coded according to the medical record. The Plan denied your request. The Plan says two of the 
billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R12 has an Excludes1 note in relation to R10.13. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for 99213 have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation 
and management services described by code 99213 performed on date of service July 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99349, 99406) provided on May 31, 2023. 
 
You asked the Plan to pay for the home visit (99349, 99406). You say that the service was medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit (99349, 
99406) provided on May 31, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 You asked the Plan to pre-approve the medication. You say that you do not use the Plan's alternative 
medications at your facility. The Plan denied your request. The Plan says the enrollee has not tried and failed 
preferred medications. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Dysport or Xeomin. Documentation 
does not support that Dysport or Xeomin would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you do not have any means of 
transportation, and are requesting the transportation to be treated for breast cancer. The Plan denied your 
request. The Plan says your benefit only allows 50 miles. The Plan also says that this request exceeds your 
benefit limit and is not covered by your health plan.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visual field examination (92083) 
provided on June 20, 2023. 
 
You asked the Plan to waive the copayment for the visual field examination (92083). You say that the services 
should be covered. 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 $20 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $20 copayment for the visual field examination (92083). This item/service falls 
within the outpatient diagnostic tests 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 visual field examination (92083) provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the wound debridement (11042) provided 
on April 27, 2023, to August 08, 2023. 
 
You asked the Plan to reduce the copayment for the wound debridement (11042). You say that the wrong cost 
share was applied. 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 $200 
copayment for outpatient hospital services. 
 
You have been asked to pay a $200 copayment for the wound debridement (11042). This item/service falls 
within the outpatient hospital services 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 reduce the copayment for 
the wound debridement (11042) provided on April 27, 2023, to August 08, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97530, 97112, 97110) provided on July 
10, 2023. 
 
You asked the Plan to pay for therapeutic services. You say that these services were pre-authorized and 
medically necessary. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R26.2 has an Excludes1 note in relation to R26.81. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for therapeutic services have not been met. Therefore, we decided that the Plan does not have to 
pay for therapeutic services (97530, 97112, 97110) provided on July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenetic testing (81225, 81226, 81227, 81231, 
81232, 81240, 81241, 81291, 81306, 81328, 81335, 81238) provided on March 10, 2023. 
 
You asked the Plan to pay for the pharmacogenetic testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenetics testing will be considered 
medically reasonable and necessary if the patient has a condition where clinical evaluation has determined the 
need for a medication that has a known gene-drug interaction(s) for which the test results would directly impact 
the drug management of the patients condition. 
 
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 pharmacogenetic testing. Our reviewer 
says that this testing was not medically necessary. Our physician reviewer found the provided documentation did not clearly list the proposed medications being considered for treatment for this patient or how this testing 
would lead to a change in treatment and overall outcome. 
 
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 pharmacogenetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for pharmacogenetic testing (81225, 81226, 81227, 81231, 81232, 81240, 81241, 
81291, 81306, 81328, 81335, 81238) provided on March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 15, 2023, billed with 
codes 87481, 87491, 87653, 87640, 87563, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that the coding is approved by Medicare. 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 NGS panel was not billed with a single 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 15, 2023, 
billed with codes 87481, 87491, 87653, 87640, 87563, 87798, 87641, and 87500.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical and occupational therapy provided on August 02, 
2023. 
 
You asked the Plan to pay for physical and occupational therapy. You say that we used a code that we have 
always used that is valid and works. Please reprocess. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical and 
occupational therapy provided on August 02, 2023.