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

We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, and 87641. billed for date of service December 8, 2021.

You asked the Plan to pay for procedure code 87150, 87481, 87653, 87798, and 87641.. You say that all codes billed should be paid. The Plan denied your request. The Plan says payment for codes 87150, 87481, 87653, 87798, and 87641. is bundled into payment for codes 87500 and 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 87150, 87481, 87653, 87798, and 87641. are column II codes to column I codes 87500 and 87801. 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 87150, 87481, 87653, 87798, and 87641. billed for date of service December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV). 
 
You asked the Plan to pre-approve a scooter. You say that you need the requested scooter to move around 
better.  The Plan denied your request. The Plan says there is no evidence that the requested scooter is medically 
necessary. You do not need a scooter to access the community. You can access the community with your car 
and a cane. 
 
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.  
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. The records 
show that you can walk in your home without an assistive device, and you use a cane in the community. The 
records also show you drive your own car to medical appointments and to do grocery shopping. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (POV).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cx bladder testing provided on July 25, 2022. 
 
You asked the Plan to pay for the Cx bladder testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 0012M for CxBladder is non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is CxBladder testing. This is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of the Cx bladder testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Cx bladder testing provided on 
July 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 on December 30, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment for code J3490 is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intra-operative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure code 64483. Payment for code J3490 is included in the global surgical package for 
64483. Therefore, we decided that the Plan does not have to pay for the drug services billed with code J3490 on 
December 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc NP. 
 
You asked the Plan to pre-approve Via Disc NP. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 Via Disc NP. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Via disc NP is purely experimental for back pain. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Via Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Via Disc NP.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the leads (A4595) provided on October 21, 2022. 
 
You asked the Plan to pay for the supplies. You say that payment was received for the enrollee's (TENS) unit. 
You say that the leads should be covered too. The Plan denied your request. The Plan says the supplies 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 pay for the supplies. Our reviewer says that the leads 
are not considered medically reasonable and necessary in this case.  Our physician reviewer found a transcutaneous electrical nerve stimulator (TENS) unit is not indicated for disuse atrophy. Therefore, the leads 
to be used with a TENS unit is not 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 the supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the leads (A4595) provided on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for the billed service. You say that the enrollee presented with an abnormal 
electrocardiogram.  The Plan denied your request. The Plan says the records do not support the billed code.  
 
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 99220 is initial observation 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.  
 
 We asked our physician 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 billed service. Our reviewer found that the enrollee 
was admitted to the hospital at an observational level of care with ST depression during induction of anesthesia 
for a planned shoulder surgery. At the time of admission, the enrollee was asymptomatic and hemodynamically 
stable. The plan of care included cardiac monitoring and rule-out for acute cardiac ischemia. His initial 
diagnostic studies were normal. In this case, the documentation does not support the CPT code 99220. The 
documentation does not indicate the encounter required medical decision making of high complexity.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99220 billed for date of service October 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023 to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you continued providing care to this 
enrollee to avoid complications. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023 to January 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan.  
 
You asked the Plan to pre-approve the PET-CT scan. You say that you are requesting reconsideration for the 
denial of a PET-CT scan. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 for the PET-CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you do not have behavioral evidence to 
suggest frontotemporal dementia. The Medicare and National Coverage Determination (NCD) rules specify 
that a PET-CT will only be approved if there are findings to suggest frontotemporal dementia versus. 
Alzheimer's disease. 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 PET-CT scan have not been met.  Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 27, 2022, to 
September 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you made attempts to timely submit your 
NOA. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 28, 2022. The NOA was not received by the Plan until October 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 27, 2022, to September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) with an ophthalmologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you were referred to this provider by a good 
friend, who had a very successful procedure with him. You are more comfortable seeing someone who has 
been personally recommended to you. The Plan denied your request. The Plan says you must receive care from 
a network provider. There are in-network providers available for this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99205) with an ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the miscellaneous vision item or service provided on 
September 9, 2022. 
 
You asked the Plan to pay for the miscellaneous vision item or service. You say that you have not received any 
payment. You say a second claim was submitted at the same time. The Plan denied your request. The Plan says 
this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the miscellaneous vision item or 
service was reimbursed by the Plan on [Please enter the date on which the prior claim was paid October 6, 
2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we 
decided that the Medicare rules for the miscellaneous vision item or service have not been met. Therefore, we 
decided that the Plan does not have to pay for the miscellaneous vision item or service provided on September 
9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case.   Our physician 
reviewer found that the treatment-plan comparison for the enrollee shows lower doses to surrounding normal 
tissues, for which the non-proton plan was unacceptable. While it is possible that better optimization of the 
non-proton plan would reduce this exposure, it is plausible (based on the extent and location of the tumor) that 
the reduction in dose to normal tissues resulting from proton beam therapy would result in a clinically 
meaningful benefit. Proton beam therapy could therefore be considered to be furnished in accordance with 
accepted standards of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have been met. Therefore, we decided that the Plan has to 
pre-approve proton beam therapy.  
 
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 the genetic testing provided on October 5, 2022, billed with 
codes 81162, 81201, 81317, 81307, 81292, 81298, 81351, 81321, 81295, 81314, 81334, 81272, 81218, 81345, 
and 81209. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 5, 2022, billed with codes 81162, 81201, 81317, 81307, 81292, 81298, 81351, 81321, 81295, 81314, 
81334, 81272, 81218, 81345, and 81209.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure cuff stocking (E1399). 
 
You asked the Plan to pre-approve a blood pressure cuff stocking. You say that you need a blood pressure cuff 
because it is medically necessary for your health conditions. Your doctor wants you to check your blood 
pressure often and send him the results. The Plan denied your request. The Plan says the requested item is not 
primarily medical in nature and not a covered benefit. 
 
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 blood pressure cuff stocking (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra. 
 
You asked the Plan to pre-approve Fasenra. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Fasenra. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of asthma. The record provided does not document the presence of 
an eosinophilic phenotype. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation.  Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fasenra have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Fasenra.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (TFESI) 
(64483, 64484). 
 
You asked the Plan to pre-approve TFESIs. You say that you want to appeal this denial. The Plan denied your 
request. The Plan says the requested injections are not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain criteria are 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 TFESIs. Our reviewer says that the 
requested TFESIs are not medically necessary. Our physician reviewer found the documentation does not 
reveal an objective physical examination, and objective concordant radiological image-based diagnostic testing 
supporting the need for transforaminal epidural steroid injections (TFESI). The most recent medical progress 
note indicated a normal neurological examination. There is no objective evidence of failure of 4 weeks of 
noninvasive conservative care. Therefore, the reviewer found that the requested TFESIs are 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 TFESIs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transforaminal epidural steroid injections (TFESI) (64483, 64484).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic propulsion tire (E2211), an insert for a 
pneumatic propulsion tire (E2213), a push handle (K0108) and a push tracker (K0108). 
 
You asked the Plan to pre-approve manual wheelchair accessories. You say that the enrollee needs a 
replacement wheelchair that better suits the enrollee's needs. The Plan denied your request. The Plan says the 
requested accessories are not medically needed and do not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The pneumatic propulsion tire and inserts are not medically needed. The wheelchair comes with wheels that are 
suitable for indoor use. The push handles are a convenience item, and the push tracker does not serve a purpose 
that is primarily medical in nature. These items are 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 
pneumatic propulsion tire (E2211), an insert for a pneumatic propulsion tire (E2213), a push handle (K0108) 
and a push tracker (K0108).