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

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an electronic connection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the complexity of your seating and positioning needs necessitates a more complex 
group 3 power wheelchair base. The electronic connection is necessary to operate the group 3 power 
wheelchair base and the power options. Therefore, the electronic connection (E2311) is 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 an electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection between wheelchair controller and two or more power seating system 
motors (E2311).  
 
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 validity testing billed with code 83789 for date(s) of service 
September 8, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental procedure codes D6010, D6057, D6058, D6104, 
and D6793. 
 
You asked the Plan to pre-approve the requested services. You say that the services will improve the enrollee's 
mastication and overall health. The Plan denied your request. The Plan says the services are not included in 
your benefit. 
 
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. 
 
 Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
procedure codes D6010, D6057, D6058, D6104, and D6793.
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 
29, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. 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 29, 2022.
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 
22, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be paid. 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 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service April 11, 
2023. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while in outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there is both a 
professional and technical component for the CPT code. In this case, an appropriate modifier to indicate the 
professional component has not been billed with CPT code 99153. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99153 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99153 billed for date of service April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81003 and 87481 (x5) billed for date of 
service April 15, 2022. 
 
You asked the Plan to pay for procedure codes 81003 and 87481. You say that these services were necessary 
and were reported appropriately. The Plan denied your request. The Plan says these codes are not supported in 
the medical record as they were reported. 
 
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 81003 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of protein, specific gravity, urobilinogen, any number of these constituents; automated, with 
microscopy. The CPT Code Manual definition of code 87481 is candida species, amplified probe technique. 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 81003 and 87481. Our reviewer says that 
these services are not supported as billed. Our reviewer found that the laboratory report does not include 
documentation of urinalysis. In addition, 5 units were reported for code 87481; however, the laboratory report 
supports: Candida albicans, Candida glabrata, Candida lusitaniae, and Candid dublinenensis. In this case, one 
unit cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 81003 and 87481 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 81003 and 87481 (x5) billed for date of service April 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (81479) provided on June 14, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
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 does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory panel (81479) 
provided on June 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse x2. 
 You asked the Plan to pre-approve home health services. You say that the enrollee's wound is not getting any 
better and continues to get worse and is unable care for itself due to lack of mobility, if not able to get the 
additional help needed to get better, this could lead to infection and other illness. The Plan denied your request. 
The Plan says the enrollee's records show the wound is small and healing and the care received does not require 
a skilled nurse to perform it.  
 
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 no acute 
medical concerns, medication or plan of care changes have been specified thus the records do not show that 2 
additional home health skilled nursing visits are required to effectively provide 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a registered nurse x2.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83880 for date of service March 6, 2023. 
 
You asked the Plan to pay for procedure code 83880. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed is 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, the CPT Code Manual definition of code 83880 is assay of natriuretic peptide. 
 
We find that CPT code 83880 is not supported in the medical record. Specifically, the submitted medical 
records include a lab report that indicate the billed services were performed by a health care provider other than 
the billing health care provider. This means the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure code 83880 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 83880 for date of service March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491, 87591, 87661, 87481, 87529, 87640, 
and 87798 billed for date of service April 20, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test is a Medicare covered service. The Plan 
denied your request. The Plan says the billed codes 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.  
 
In this case, we have confirmed that code 87491, 87591, 87661 is a column II code to column I code 87801. 
These codes have not been billed with an appropriate modifier to bypass the edit. We find that codes 87481, 
87529, 87640, and 87798 are not supported in the medical records. The documentation shows that panel testing 
was provided. The records do not show that codes 87481, 87529, 87640, and 87798, billed with the -59 
modifier were separate and distinct services. 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 87491, 87591, 87661, 
87481, 87529, 87640, and 87798 billed for date of service April 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the IRF admission.  
 
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 on review of the available records, the enrollee with debility, and fracture of right 
humerus, as described above does not meet CMS coverage criteria for IRF admission. The enrollee is 
medically stable. The clinical documentation does not support necessity for admission to an IRF. The 
complexity of the enrollees medical, rehab, and nursing needs does not require acute hospital inpatient rehab 
stay with an interdisciplinary approach to rehabilitative care. The enrollees rehab needs can be safely provided 
in an alternate and low intensity setting such as in a skilled nursing facility.  
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87900 and 87899 billed for date of service 
November 29, 2022. 
 
You asked the Plan to pay for procedure codes 87900 and 87899. You say that these services were necessary 
and were reported with covered codes. The Plan denied your request. The Plan says this code is not supported 
in the medical record. 
 
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 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. The CPT Code Manual definition of code 87899 
is infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; 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 procedure codes 87900 and 87899. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found code 87900 is not supported as the 
record indicates that this testing was performed on urine. According to the description of 87900 in the Coder's 
Desk Reference, this test is performed on plasma. Code 87899 is not supported, as the record does not mention 
direct optical/visual observation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87900 and 87899 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87900 and 87899 billed for date of service November 
29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you request a medical review to bypass the 
MIA3 edit based on medical necessity. The Plan denied your request. The Plan says payment for code 81345 is 
bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service November 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary breast cancer-related disorders panel (81432, 
81433) provided on June 6, 2023. 
 
You asked the Plan to pay for the hereditary breast cancer-related disorders panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the hereditary breast cancer-related disorders panel have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary 
breast cancer-related disorders panel (81432, 81433) provided on June 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service June 20, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 18 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a calf rest/pad, replacement only (E0995). 
 
You asked the Plan to pre-approve a calf rest/pad, replacement only. You say that the item is necessary. The 
Plan denied your request. The Plan says the enrollee has been approved for a new power wheelchair and the 
requested replacement part is not required. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has been approved for a new power wheelchair that does not require 
replacement parts. Therefore, we decided that the Plan does not have to pre-approve a calf rest/pad, 
replacement only (E0995).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS system (33289). 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 CardioMEMS system. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. 
 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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a CardioMEMS system (33289).