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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and a garment. You say that you disagree 
with the denial and are requesting reconsideration. The Plan denied your request. The Plan says the records do 
not show at least four-week trial of daily, multiple-hour home usage of the basic pump, or a four-week trial of 
conservative therapy including regular and compliant use of compression bandage, regular exercise, and limb 
elevation. There is no indication of chest, trunk and/or abdominal lymphedema. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous transluminal intravascular coronary 
lithotripsy (C1761, 0715T) provided December 27, 2022. 
 
You asked the Plan to pay for the outpatient surgery. You say that you are sending the medical reds o show 
medical necessity for these charges. The Plan denied your request. The Plan says Intracoronary lithotripsy is 
considered investigational, and more research is needed to show the safety and efficacy of the procedure 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The clinical value and effectiveness of intracoronary lithotripsy in the setting of coronary artery disease have not been demonstrated in the peer-reviewed literature. Based on this 
information, we decided that Medicare rules for coverage of the outpatient surgery have not been met. 
Therefore, we decided that the Plan does not have to pay for the percutaneous transluminal intravascular 
coronary lithotripsy (C1761, 0715T) provided December 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional hours of neuropsychological testing (96133, 
96139). 
 
You asked the Plan to pre-approve 7 additional hours of neuropsychological testing. You say that the additional 
hours are necessary for you to provide appropriate care for the enrollee. The Plan denied your request. The Plan 
says there is no documentation explaining why extended testing time is medically necessary beyond the 
previously approved hours. 
 
The Plan follows Medicare rules. Medicare rules say that typically, psychological testing will require from four 
(4) to six (6) hours to perform, including administration, scoring and interpretation. Supporting documentation 
in the medical record must be present to justify greater than 8 hours per patient per evaluation. 
 
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 7 additional hours of 
neuropsychological testing. Our reviewer says that the additional hours of testing are not shown to be justified. 
Our physician reviewer found the record shows that the enrollee has been approved for 8 hours of testing. 
There is no clear documentation available for review that would indicate a medical reason for additional formal 
neuropsychiatric or psychological testing.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 additional hours of neuropsychological testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 7 additional hours of neuropsychological testing (96133, 
96139).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services billed with code 00530 for September 
4, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that clinical trial claims shall include a HCPCS modifier 
Q0 or Q1 as appropriate. 
 
We looked at the file and Medicare rules. The file shows that the services were billed as part of a clinical trial 
but were not billed with the required Q0 or Q1 modifier. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services billed with code 00530 for September 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99309 and G8427 billed for date of service 
July 14, 2023. 
 
You asked the Plan to pay for procedure codes 99309 and G8427. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 99309 and G8427 is not supported. Specifically, codes 99309 and G8427 have been 
billed with modifier "HE," which designates a non-covered service. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99309 and G8427 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99309 and G8427 billed for date of service July 14, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 28, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 10, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard Esophageal DNA test (0114U) provided July 
5, 2023. 
 You asked the Plan to pay for the laboratory service. You say that you are appealing the denial for EsoGuard 
that was denied as non-covered routine, screening exam. The Plan denied your request. The Plan says per the 
DEX Diagnostics Exchange Registry, EsoGuard is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the EsoGuard Esophageal DNA test (0114U) provided July 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
March 22, 2023. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel rendered on March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87797, 87653, 87651, 87641, 87591, 87563, 
87532, 87529, 87500, 87496, 87491, 87481, G0452) provided on July 13, 2023. 
 
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 this claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service. 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 (87797, 87653, 87651, 87641, 87591, 87563, 
87532, 87529, 87500, 87496, 87491, 87481, G0452) provided on July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150-XU and 87324-XU provided on June 
29, 2023. 
 You asked the Plan to pay for procedure codes 87150-XU and 87324-XU. You say that the medical records 
support the billing of codes 87150-XU and 87324-XU. The Plan denied your request. The Plan says the 
medical records do not support the billing of codes 87150-XU and 87324-XU. 
 
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 87324 is a column II code to column I code 87506, and code 87150 is 
a column II code to column I code 87500; however, codes 87324 and 87150 were billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87150-XU and 87324-XU. Our reviewer 
says that the medical records do not support the billing of codes 87150-XU and 87324-XU. Our reviewer found 
the provider reported procedure code 87324 with appended modifier XU Unusual non-overlapping service to 
bypass NCCI Edit with CPT 87506, however the laboratory report does not include documentation to support 
rationale for billing procedure code separately. Therefore, this procedure and modifier cannot be verified. 
 
The provider reported procedure code 87150 with appended modifier XU Unusual non-overlapping service to 
bypass NCCI Edit with CPT 87500, however the laboratory report does not include documentation to support 
rationale for billing procedure code separately. Therefore, this procedure and modifier 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 87150-XU and 87324-XU have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150-XU and 87324-XU provided on June 29, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64495, 99152, and J2250 rendered on 
February 8, 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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 64495: 
 
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
Healthcare Common Procedure Coding System (HCPCS) J2250: 
 
Injection, midazolam hydrochloride, per 1 mg 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records do not 
document injections at a third level, only a L3-4 and L4-5. Therefore, the records do not support CPT 64495. 
 
Additionally, the provided records in this case do not document the presence of an independent trained 
observer to assist in the monitoring of the patient's level of consciousness and physiological status. Therefore, 
the records do not support CPT 99152 in this case. 
 
Finally, in terms of J2250, the provided records in this case do not document a midazolam hydrochloride 
injection; the records document only local anesthesia.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 64495, 99152, and J2250 rendered on February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service June 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of treatment. The 
Plan denied your request. The Plan says the billed code cannot be separately reimbursed. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is not supported. Code J3490 was billed to identify Bupivacaine, which is a local anesthetic. If performed to 
facilitate the infusion or injection or hydration, the use of local anesthesia is included and not separately 
billable. 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 procedure code J3490 billed for date of 
service June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves. 
 
You asked the Plan to pre-approve non-sterile gloves. You say that you would like reconsideration because the 
requested non-sterile gloves are medically necessary. The Plan denied your request. The Plan says this item is 
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 non-sterile gloves.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on July 21, 2023, billed with 
codes 87635, 87502, 87503, 87486, 87541, 87581, 87651 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on July 21, 2023, billed with codes 87635, 87502, 87503, 87486, 87541, 87581, 87651 and 
87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for procedure code 87086. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 87086 is not supported. Specifically, the identification code reported on the claim for 
the rendering laboratory does not match the identification code on the provided medical records. Based on this 
information, we decided that Medicare rules for coverage of procedure code 87086 have not been met.  
  Therefore, we decided that the Plan does not have to pay for procedure code 87086 billed for date of service 
February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service March 3, 
2023. 
 
You asked the Plan to pay for procedure code 99309. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 99309 is not supported. Specifically, code 99309 has been billed with modifier "HE," 
which designates a non-covered service. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99309 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99309 billed for date of service March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 2, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 2, 2023.