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

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple 
power options. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no need for the multiple power options. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you are not at high risk for skin breakdown. The enrollee does not use intermittent 
catheterization, and does not have spasticity. You have the capacity to manage your upper body activities of 
daily living activities, and have adequate upper body strength to control and manage the standard 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 heavy duty power wheelchair with multiple power options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interpretation of an electrocardiogram (93010) provided on 
December 7, 2022. 
 
You asked the Plan to pay for interpretation of an electrocardiogram. You say that you have billed the service 
at issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for interpretation of an electrocardiogram until the primary insurer has denied the claim for these services. In 
this case, you have not provided sufficient information about the primary insurer's denial for the Plan to 
coordinate benefits. Therefore, we decided that the Plan does not have to pay for interpretation of an 
electrocardiogram (93010) provided on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on January 26, 2023.

You asked the Plan to waive the copayment for podiatry services. You say that you disagree with the copayment. 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 podiatry services.

You have been asked to pay a $40 copayment for podiatry services. This item/service falls within the podiatry services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have waive the copayment for podiatry services provided on January 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 10, 2022, to 
December 9, 2022. 
 You asked the Plan to pay for the home health services. You say that the Plan's denial reason is unclear.  You 
believe that your claim is a clean claim that meets all billing requirements. 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 November 10, 2022. The NOA was not received by the Plan until 
December 30, 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 November 10, 2022, to December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service January 3, 
2023. 
 
You asked the Plan to pay for procedure code A4239. The Plan denied your request. The Plan says procedure 
code A4239 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 A4239 has a status indicator of P on the Physician Fee Schedule. This means that procedure code A4239 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service January 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11424, 11626, and 12044 rendered on 
November 14, 2022. 
 
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 11424: 
 
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm 
 
CPT 11626: 
 
Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm 
 
CPT 12044: 
 
Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm 
 
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 CPT codes 11424 and 11626 are 
not supported by the medical record. Although the excisions were documented, the diameter of the lesions is 
not documented. According to CPT rules, code selection is determined by measuring the greatest clinical 
diameter of the apparent lesion plus that margin required for complete excision. It cannot be verified that a 
malignant lesion with a diameter of over cm was excised. It cannot be verified that a benign lesion of 3.1 to 4 
cm was excised. Additionally, CPT code 12044 is not supported. The laceration repairs do not mention layered 
or intermediate closure. Simple closure is included in the excisions. 
 
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 11424, 11626, and 12044 rendered on November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis (0037U). 
 You asked the Plan to pre-approve a targeted genomic sequence analysis. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that effective for services performed on or after March 16, 
2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing 
(NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a 
Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating 
physician, and when all requirements 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 a targeted genomic sequence analysis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do 
not show that your cancer is recurrent, relapsed, refractory metastatic, or advanced (Stage III or IV). The 
review has determined that you do not meet the coverage criteria detailed in the LCD. 
 
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 targeted genomic sequence analysis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a targeted genomic sequence analysis (0037U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 20, 2022, billed 
with codes 81307, 81317, 81298, 81238, 81321, 81249, 81223, 81334, 81307, 81320, 81279, 81339, 81345, 
81216, 81305, 81241, 81250, 81209 and 81242. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically 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 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 
November 20, 2022, billed with codes 81307, 81317, 81298, 81238, 81321, 81249, 81223, 81334, 81307, 
81320, 81279, 81339, 81345, 81216, 81305, 81241, 81250, 81209 and 81242.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says a power wheelchair is not required for activities of daily living at home, and it is 
not medically necessary. 
 
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.  
 
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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that you are 
able to complete mobility-related activities of daily living (MRADLs) with a manual wheelchair. The record 
does not consistently show that you require a power wheelchair to manage activities of daily living in the 
home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid swing and stance phase control (L5828), fluid 
stance extension (L5848), microprocessor control feature (L5856), flex-walk system or equal (L5981), axial 
rotation unit (L5984), stance flexion feature (L5845) and vertical shock reducing pylon feature (L5988). 
 You asked the Plan to pre-approve the items. You say that the enrollee is very active as a K3 ambulator. The 
Plan denied your request. The Plan says the request for an advanced foot and electronic knee with a shock 
reducing pylon cannot be approved at this time. 
 
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 the items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not support that the enrollee is a K3 ambulator, given the need for a cane prior to 
amputation. There is no support in the physician documentation that the enrollee is participating in high impact 
activity that needs a vertical loading pylon. Furthermore, the physician documentation does not support that the 
enrollee's activities require a heavier microprocessor need over a mechanical knee given his comorbidities. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fluid swing and stance phase control (L5828), fluid stance extension (L5848), microprocessor 
control feature (L5856), flex-walk system or equal (L5981), axial rotation unit (L5984), stance flexion feature 
(L5845) and vertical shock reducing pylon feature (L5988).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 232 units of air ambulance mileage (A0436) billed for date 
of service September 27, 2022. 
 
You asked the Plan to pay for 232 units of air ambulance mileage. You say that these services were medically 
necessary and appropriate. The Plan denied your request. The Plan says the number of units billed in this case 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 232 units of CPT code A0436 are not supported in the medical record. The air ambulance mileage 
distance between the starting and ending locations of enrollee transport does not amount to 232 miles. Based on 
this information, we decided that Medicare rules for coverage of 232 units of air ambulance mileage have not 
been met. Therefore, we decided that the Plan does not have to pay for 232 units of air ambulance mileage 
(A0436) billed for date of service September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the long-term electroencephalogram (EEG) (95716) 
provided July 2022. 
 
You asked the Plan to pay for  the diagnostic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this service is considered 
experimental or investigational by the Plan. 
 
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 diagnostic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has history of a seizure disorder that is maintained on 
medical therapy with Levetiracetam. Per the reviewed literature, video EEG monitoring may be considered 
medically necessary: to diagnose seizure type and epilepsy syndrome in individuals who present diagnostic 
difficulties following clinical assessment and standard EEG; for identification and localization of a seizure 
focus in individuals with intractable epilepsy who are being considered for surgery; to monitor neonates with 
hypoxic-ischemic encephalopathy (HIE) who are being treated with therapeutic hypothermia and to document 
provocation of seizures after medication withdrawal for the purpose of making medication adjustments or 
otherwise determining an appropriate treatment plan. In this case there was no specific clinical rationale for the 
long-term electroencephalogram. The review has determined that the items/services at issue in this are not case 
medically reasonable and 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 diagnostic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for  the long-term electroencephalogram (EEG) (95716) provided July 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 for January 30, 
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 are not separately payable. 
 
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 date of 
service as minor surgical procedure 20526. Payment for code J3490 is included in the global surgical payment 
for code 20526. Therefore, we decided that the Plan does not have to pay for the drug services billed with code 
J3490 for January 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neuropsychological testing (96131 x 5 units, 96137 
x 6 units). 
 
You asked the Plan to pre-approve the neuropsychological testing. You say that the services are medically 
necessary. The Plan denied your request. The Plan says these are considered to be self-administered or self-
scored rating scales or screening measures which can be administered without psychological testing. 
 
The Plan follows Medicare rules. Medicare rules say that 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 the neuropsychological testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found this patient does not 
meet the criteria and it is unclear what questions are to be answered by neuropsychological 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 the neuropsychological testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the neuropsychological testing (96131 x 5 units, 96137 x 6 units).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 95861 rendered on 
August 4, 2022. 
 
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. 
 
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 there was no evidence in the 
records that CPT 95861 was rendered twice. The technical report cites that the electromyography was of the 
lower level with recording sites of abductor hallucis, adductor longus, gastroc, tibialis anterior, vastus medialis, 
and vastus lateralis. There is no evidence that this service was done twice. 
 
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 an additional unit of procedure code 95861 rendered on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service April 28, 
2022 to April 29, 2022. 
 
You asked the Plan to pay for procedure code S9338. You say that you have provided medical records to 
support payment. 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 S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service April 28, 2022 to April 29, 2022.