Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health physical therapy visits (G0151).  

You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found records do not 
support that the complexity of the enrollee's conditions are such that the skills of a professional therapist are 
required to achieve further improvement in the enrollee's symptoms or functional status. Further utilization of 
the home exercise program and/or transition to outpatient therapy appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 home health physical therapy visits (G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medium wave bath chair (E1399). 
 
You asked the Plan to pre-approve a bath chair. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a medium wave bath chair (E1399).
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 
27, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you have billed the service at issue 
correctly. 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 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on March 28, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you feel that this service 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 $40 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided on February 14, 2023. 
 
You asked the Plan to pay for 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 pay for a core 
buildup (D2950) provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with single power 
option with additional features. 
 
You asked the Plan to pre-approve a group 3 PWC with single power option with additional features. You say 
that the items are medically necessary. The Plan denied your request. The Plan says the enrollee does not have 
high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of 
managing power drive. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power options is covered 
if the criteria listed in the Medicare rules section is met. 
 
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 group 3 PWC with single power 
option with additional features. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. 
 
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 group 3 PWC with single power option with additional features have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with 
single power option with additional features.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899, 87900, and 87652 for date of service 
October 10, 2022. 
 
You asked the Plan to pay for procedure codes 87899, 87900, and 87652. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87899, 87900, and 87652 are not supported in the medical record. Specifically, the 
laboratory results provided within the medical records does not include a rapid test kit that shows collected 
samples of the infection agent, by a swab or aspirations using several reagents; therefore, codes 87899 cannot 
be verified. Code 87900 is for infectious agent drug susceptibility phenotype prediction using regularly updated 
genotypic bioinformatics; however, the medical records attached did not include documentation that 
quantitative infectious agent drug susceptibility completed with assessment was provided.  Code 87652 is for 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification when 
performed. The laboratory results provided indicates that testing of Streptococcus, group A; amplified probe 
technique infectious agent was performed, but it does not include separate testing results to meet the code 
criteria of CPT 87652. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87899, 87900, and 
87652 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87899, 
87900, and 87652 for date of service October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481-XU, 87653-XU, and 87798-XU 
billed for date of service August 16, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 87481, 
87653, and 87798 are 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 codes 
87481, 87653, and 87798 are column II codes to column I code 87801. The codes at issue were billed with the 
XU modifier. The records provided did not show the services were distinct components of the main 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 codes 87481-XU, 87653-XU, and 87798-XU billed for date of service 
August 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided on April 2, 
2023. 
 
You asked the Plan to pay for the medication. You say that you would like the medical documentation to be 
reviewed and the claim to be reprocessed for payment. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided on April 2, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation code P9603 billed for date of service 
December 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were submitted. The Plan 
denied your request. The Plan says the records do not include travel documentation. 
 
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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the records provided do not 
corroborate traveled miles for the lab services. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
transportation code P9603 billed for date of service December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have 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 there is no documentation provided to support the expectation you will 
require a greater than 2 midnight stay. 
 
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 does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found you are approved for a left revision carpal tunnel release with biopsy and 
cultures. The record does not document that the treating physician has a reasonable expectation of a length of 
stay spanning 2 or more midnights. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010 x3), bone 
graft at time of implant placement (D6104 x3), implant supported retainer (D6075 x2) and implant supported 
porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to eat properly and are 
having headaches and jaw pain because of the extensive damage to your teeth due to a fall. You say this should 
be considered medical instead of dental because it is the direct result of a fall. The Plan denied your request. 
The Plan says implant services are not a covered benefit under the plan. 
 
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. The requested services are also not eligible for coverage under the 
medical benefit which is limited to surgery of the jaw or related structures, setting fractures of the jaw or facial 
bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services 
that would be covered when provided by a physician. Therefore, we decided that the Plan does not have to pre-
approve surgical placement of implant body (D6010 x3), bone graft at time of implant placement (D6104 x3), 
implant supported retainer (D6075 x2) and implant supported porcelain/ceramic crown (D6065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87641 for date of service 
September 9, 2022. 
 
You asked the Plan to pay for procedure codes 87150 and 87641. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87150 and 87641 are not payable as billed. Specifically, codes 87150 and 87641 were 
billed with the XU modifier. the medical records provided do not support that these services were an unusual 
non-overlapping service from the other services performed; therefore, the use of the XU modifier on these 
codes are not supported. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 87150 and 87641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87150 and 87641 for date of service September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9 months use of a ventilator. You say that medical documents have been 
submitted to support the medical necessity of the denied ventilator. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for approval of a ventilator. 
 
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 use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of obesity hypoventilation syndrome. With this request for continuation of the NIV, there was a 
standard written order dated June 23, 2023, that indicates the device is being ordered for average volume-
assured pressure support-automated expiratory (AVAPS-AE) mode. The compliance data submitted by the 
durable medical equipment provider from the time period of June 21, 2023, to July 20, 2023, indicates the 
machine is being used in AVAPS-AE mode which is a bi-level pressure mode, and no other modes. The 
enrollee was evaluated by his provider on July 18, 2023, and the visit notes say that he was referred to a weight 
loss management clinic. The documentation submitted fails to indicate that he is requiring the ventilator for use 
in other than bilevel positive airway pressure (BiPAP) or a bi-level pressure mode as a respiratory assist device 
(RAD). Ventilators used solely as a RAD are considered not reasonable and necessary per Medicare 
Guidelines. The documentation provided does not support that the use of a BiPAP or bi-level pressure mode 
would not meet your current medical needs or has been found to be ineffective in the home setting. There is no 
supporting documentation that this ventilator is being used as intended. The review has determined that this 
enrollee does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure 
consequent to chronic obstructive pulmonary disease. The documentation in the medical record does not 
support that the ventilator at issue is medically necessary and reasonable for this enrollee. 
 
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 use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) months use of a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798 x13 and 87481 x4) provided on 
November 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87798 x13 and 87481 x4) provided on 
November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640-59 and 87491-59 billed for date of 
service February 17, 2023. 
 
You asked the Plan to pay for procedure code 87640. You say that the coding is approved by Medicare. The 
Plan denied your request. The Plan says the billed services remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641. The medical 
records provided do not show that code 87640 was a distinct procedural service. Based on this information, we 
decided that the Medicare rules for coverage have not been met.  
 
In this case, the CPT Code Manual definition of code 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. We find that code 87491 is not supported in the 
medical record. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87640-59 and 87491-59 billed for 
date of service February 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical placement of a prostate rectal spacer device 
(SpaceOAR) (55874) and ultrasound (76872). 
 
You asked the Plan to pre-approve the SpaceOAR device. You say that the surgery would help provide relief 
and comfort. You also say that this would relieve some of your pain. The Plan denied your request. The Plan 
says the surgical placement of the SpaceOar Rectal Spacer is not appropriate or reasonable based on lack of 
medically necessity for the device. 
 
The Plan follows Medicare rules. Medicare rules say that polyethylene-glycol (PEG) hydrogel is covered once 
in patients with clinically localized prostate cancer with low or favorable intermediate prostate cancer. 
 
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 SpaceOAR device. Our reviewer 
says that the requested SpaceOAR device is not medically necessary. Our physician reviewer found the 
provided documentation indicates the enrollee has unfavorable intermediate prostate cancer with at least two 
intermediate risk factors. Therefore, the reviewer found that the SpaceOAR device is not medically reasonable 
or 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 the SpaceOAR device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a surgical placement of a prostate rectal spacer device (SpaceOAR) (55874) and 
ultrasound (76872).