Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 1, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible 
and available and requires authorization for certain services. No medical necessity for an out-of-network 
provider such as an urgent or an emergent situation that has been documented.  
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on November 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective 
surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee needs this surgery. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. The planned procedure is not listed on the CMS Inpatient Only List. The 
procedure is currently approved as an ambulatory procedure. There is no documentation provided to support 
the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the 
record does not show that at the time of inpatient admission the admitting physician reasonably expected that 
the enrollees necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care associated with an elective surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 tests purchased between April 29, 2022, 
to September 29, 2022. You asked the Plan to pay for at-home COVID-19 tests. 

You say that these tests should be reimbursed. The Plan denied your request. The Plan says these tests were not covered by your Medicare Advantage Plan at the time of purchase; only Original Medicare paid for these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and at-home 
COVID-19 tests is an OTC item. Your Plan did not offer supplemental coverage of these tests at the time of 
services. These tests were covered on the dates in question by Original Medicare rather than your Medicare 
Advantage plan. The Plan is not responsible in this case. Therefore, we decided that the Plan does not have to 
pay for at-home COVID-19 tests purchased between April 29, 2022, to September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 11, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says although there are three requested power options (tilt, recline and elevating 
leg rests), there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-
proportional input devices. The enrollee does not require a separate display, other electronic devices, or an 
attendant control. Our reviewer found that the documentation does not support that it is medically necessary to 
control the three approved wheelchair power options through the joystick. Our physician reviewer also found 
that the enrollee's upper extremity strength and functional ability as evidenced by being independent for 
feeding should be sufficient to control any power options through their own switches. 
 
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, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Vitrectomy face down recovery system 
(99070) purchase November 2, 2022. 
 
You asked the Plan to reimburse you for the face down recovery system. You say that you are appealing this 
decision about your refund. The Plan denied your request. The Plan says these types of devices are considered 
precautionary devices and also can be used for purposes other than the treatment of an illness or injury. 
 
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 reimburse you for the Vitrectomy face down recovery system (99070) 
purchase November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
28, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J7323 billed for date of service February 25, 
2022.  
 
You asked the Plan to pay for procedure code J7323. You say that you disagree with the denial. 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 J7323 is 2. The MAI value for this code is 3. You billed 3 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 J7323 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code J7323 billed for date of service February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hand-finger orthoses (L3808, L3913) provided from March 
22, 2023, to April 17, 2023. 
 
You asked the Plan to pay for hand-finger orthoses. You say that the items at issue were a necessity for your 
care. 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 for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The case record indicates that the items at issue in this appeal are for use outside of the home. Although these 
items may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pay for hand-finger orthoses (L3808, L3913) provided from March 22, 
2023, to April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 21, 2022, billed 
with procedure codes 99152, 99153, and J3490. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support codes 99152 
and 99153, and code J3490 is included in global package. 
 
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 codes 99152, 99153, and J3490 is 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, 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; each additional 15 minutes intraservice time (List separately in 
addition to code for primary service), and unclassified drugs. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that procedure codes 99152 and 99153 
cannot be verified, as CPT criteria is not documented in the procedure report.  
 
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 practitioner services provided have not been met. Payment for code J3490 is 
a local anesthetic and is not separately payable. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on December 21, 2022, billed with procedure codes 99152, 99153, and J3490.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284 billed for date of service December 12, 2022. 
 
You asked the Plan to pay for code 99284. You say that code 99284 was billed correctly. The Plan denied your 
request. The Plan says code 99284 was not supported because the presenting problem was not a high-risk 
threat. As a result, code 99283 was paid instead. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. 
 
 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 code 99284. Our reviewer says that code 99284 is not 
supported by the medical record. Our reviewer found the patient presented with left arm swelling and pain. She 
had a computed tomography scan of her brain and spine for left upper arm pain. This does not support code 
99284. The documentation supports an appropriate exam, but not an appropriate history or medical decision 
making of moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99284 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99284 billed for date of service December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), polycarbonate lenses (V2784), 
anti-reflective coating (V2750), a routine eye examination (S0621), and a determination of refractive state 
(92015) provided on March 29, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781), polycarbonate lenses (V2784), anti-reflective 
coating (V2750), a routine eye examination (S0621), and a determination of refractive state (92015). You say 
that you had an eye examination and new glasses were prescribed by your doctor. You also say that your 
provider and his assistant affirmed there would be no cost. The Plan denied your request. The Plan says the 
charge exceeds the allowable rate for the service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 toward the retail price of the purchase and fitting of your eyeglasses. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $300 benefit toward the purchase 
and fitting of eyeglasses (1 per calendar year). The Plan rules also say that you are responsible for any amount 
over the $300 retail price. Based on this information, we decided that the Plan's rules for coverage of 
progressive lenses (V2781), polycarbonate lenses (V2784), anti-reflective coating (V2750), a routine eye 
examination (S0621), and a determination of refractive state (92015) have not been met. Therefore, we decided 
that the Plan does not have to pay for progressive lenses (V2781), polycarbonate lenses (V2784), anti-reflective 
coating (V2750), a routine eye examination (S0621), and a determination of refractive state (92015) provided 
on March 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514).  
You asked the Plan to pre-approve kyphoplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of back fracture bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (procedure code 99291) rendered on 
August 11, 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 code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
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 99291 is a timed procedure 
code, in this case, procedure report does not include documentation of time spend with critical care services, 
and therefore service cannot be verified. Additionally, the modifier 25 cannot be verified as the procedure 
report does not contain enough documentation to verify the procedure billed. 
 
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 critical care services (procedure code 99291) rendered on August 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 16, 2023 to 
March 9, 2023. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. 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 February 16, 2023. The NOA was not received by the Plan until March 20, 
2023. 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 
on February 16, 2023 to March 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided February 2, 2023 to February 
14, 2023. 
 You asked the Plan to pay for the home health services.. You say that this service was medically necessary. 
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 plan did not receive an NOA. The claim was billed with type of bill 322. Without a NOA, the 
claim cannot be paid. Therefore, we decided that the Plan does not have to pay for home health services 
provided February 2, 2023 to February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77385 and 84153 billed for date of service 
August 15, 2022. 
 
You asked the Plan to pay for procedure codes 77385 and 84153. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the billed codes are 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 77385 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77385 is not valid for Medicare purposes. Procedure code 84153 has a Status Indicator of X. 
This means that procedure code 84153 is a statutory exclusion. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 77385 and 84153 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 77385 and 84153 billed for date of service August 15, 
2022.