Persius/hicric huggingface dataset:
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 
December 1, 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 December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient needs a home ventilator because 
they require a mouthpiece not available on other machines. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary because the patient's needs can be met with a bilevel positive airway 
pressure (BiPAP) device with average volume-assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee is a 62-year-old 
male with chronic obstructive pulmonary disease (COPD). The submitted pulmonary evaluation is limited to 
arterial blood gas analysis (ABG) showing hypercarbia (pH 7.47, PaCO2 68, and PaO2 52). You did not submit 
any additional pulmonary information including baseline arterial blood gas analysis (ABG), complete 
pulmonary function testing (PFT), polysomnography (PSG), or oximetry. The member was recently admitted 
to acute care for COPD and acute on chronic respiratory failure (ACRF) and improved with appropriate 
therapies that included standard BiPAP. The addition of volume assurance may benefit this member and the 
need for positive pressure ventilation is not disputed. However, you did not submit a compelling rationale that 
supports use of a home mechanical ventilator (HMV) to deliver this assistance rather than a BiPAP with a 
backup rate and AVAPS. The member does not appear to have the severity of illness that would justify the 
need for a home mechanical ventilator (HMV). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 
12, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 item at issue in this appeal is for use outside of the home. Although this item 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 the pneumatic compression device provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99226 billed for date of service January 7, 2023. 
 
You asked the Plan to pay for code 99226. You say that this claim was denied incorrectly. The Plan denied 
your request. The Plan says this code is no longer valid. 
 
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 American Association of 
Professional Coders has the following statement: "Effective Jan. 1, 2023, hospital observation codes 99217-
99220 and 99224-99226 are deleted. These services are merged into the existing hospital inpatient services 
codes 99221-99223, 99231-99233, and 99238-99239, and the subsection is renamed Inpatient Hospital or 
Observation Care."  As a result, observation services should be billed with a different code for the date of 
service in dispute in this appeal. 
 
 
 Based on this information, we decided that Medicare rules for coverage of code 99226 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 99226 billed for date of service January 7, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no documentation of chronic carbon dioxide (CO2) retention with an arterial blood gas 
(ABG) done while stable. If that is present, the enrollee may benefit from bilevel positive airway pressure 
(BiPAP) during sleep as an outpatient. This has not been shown to fail as an outpatient. Medicare does not 
cover a home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that 
can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
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 
January 11, 2023.  
 
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 January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88313, 88346, 88350 and 88305 billed for 
date of service September 6, 2022. 
 You asked the Plan to pay for procedure code(s) 88313, 88346, 88350 and 88305. You say that these services 
were necessary and are supported in the medical record. 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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88313, 88346, 88350 
and 88305. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88313, 
88346, 88350 and 88305. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88313, 88346, 88350 and 88305 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88313, 88346, 88350 and 88305 billed for date of service September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 17, 2022, billed 
with codes 81201, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, & 81404. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 
December 17, 2022, billed with codes 81201, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 
81401, & 81404.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L1 (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested procedure is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is covered when all of the inclusion 
criteria are met and meets none of the exclusion criteria. 
 
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 kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that there is noted to be 5mm retropulsion 
of the upper portion of the compression fracture's endplate. Additionally, the magnetic resonance imaging also 
corroborated other lumbar pathology that could plausibly be contributing to the low back pain. Therefore, the 
enrollee does not meet the coverage criteria for the requested kyphoplasty at L1. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at L1 (22514).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve T6 Kyphoplasty, represented by CPT code 22513. 
 
You asked the Plan to pre-approve T6 Kyphoplasty. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is covered 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 T6 Kyphoplasty. Our reviewer says that 
the documentation supports that the requested services are medically reasonable and necessary. Our physician 
reviewer found the enrollee was diagnosed with T6 subacute compression fracture. The enrollee presented 
status post fall with increasing thoracic back pain. The magnetic resonance imaging on June 1, 2023, 
documents compression fracture of the T6 vertebral body with marrow edema. Minimal retropulsion of the 
posterior inferior end plate into the spinal canal is seen with disc material underneath. The enrollee has a 
subacute fracture. There is Minimal retropulsion with no impact on the cord. Therefore, the enrollee meets 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T6 Kyphoplasty have been met. Therefore, we decided that the Plan has to pre-
approve T6 Kyphoplasty, represented by CPT code 22513.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 30, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you were visiting your daughter in 
outside of Portland when you started experiencing heart irregularities. You say that you went the emergency 
room, and the hospital immediately admitted you to the hospital. You say that the next day the doctor told you 
that you may only have one more day to live. The Plan denied your request. The Plan says that the care was 
received from an out-of-network provider without prior authorization.  
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health. The rules also say that Medicare 
health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding 
its decision to deny coverage or payment. 
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. In addition, the Plan has not made reasonable and diligent efforts 
to gather and forward us information needed for our review. The Plan did not provide any medical records or 
evidence of having made reasonable attempts to obtain medical records. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided on November 30, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing home visit provided on September 29, 2022. 
 
You asked the Plan to pay for the nursing home visit. You say that there should be no cost sharing associated 
with this service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nursing home visit 
provided on September 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0428) provided on July 18, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says this service is 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 CPT code. 
 
We find that CPT codes A0425 & A0428 are not supported in the medical record. Specifically, the records 
show that the enrollee was an inpatient at the time of this service. The transport service is included in payment 
to the hospital. Based on this information, we decided that Medicare rules for coverage of the ambulance 
services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services 
(A0425, A0428) provided on July 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the prostate specific antigen, total (84153, 81454) and hemoglobin, 
glycated (83036) provided November 11, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you received a bill from the provider, and 
you feel it should only be $5.00. The Plan denied your request. The Plan says that the provider is in network 
however, medical necessity cannot be determined. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory service by a contract provider and the laboratory provider is also a 
contract provider. The file does not show that the Plan provided notice that the laboratory service would not be 
covered. Under Medicare rules, this means the laboratory service is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for the prostate specific antigen, total (84153, 81454) and 
hemoglobin, glycated (83036) provided November 11, 2022.  
 
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 lab services provided on October 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CardioMEMS for date of service May 3, 2022. 
 
You asked the Plan to pay for CardioMEMS. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for CardioMEMS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the enrollee has recurrent congestive heart failure (CHF).  The CardioMEMS device was approved by the FDA in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with CHF. The clinical study on 
which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients 
in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection 
fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pay for CardioMEMS for date of service May 3, 2022.