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

 
We decided that the Plan does not have to pre-approve a K3 foot to replace a K2 foot (codes L5981 and 
L5986). 
 
You asked the Plan to pre-approve K3 foot. You say that the enrollee was provided a K2 foot, but needs a K3 
foot, and the current socket no longer fits which causes pain and redness. The Plan denied your request. The 
Plan says the notes do not show that the enrollee's currently foot does not meet the enrollee's medical needs and 
there is no documented physiological change or irreparable damage requiring a new prosthesis. 
 
The Plan follows Medicare rules. Medicare rules state that replacement of prosthetic components may be 
covered if there is a change in the physiological condition of the enrollee, an irreparable change in the 
condition of the device, or the cost of repairs would be more than 60% of the cost of a replacement. 
 
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 K3 foot. Our reviewer says that the 
enrollee does not meet criteria for this item. Our physician reviewer found the documentation does not support 
that the enrollee's current foot is not meeting the enrollee's needs. There is no physiologic change or irreparable 
change requiring a new prosthesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K3 foot have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a K3 foot to replace a K2 foot (codes L5981 and L5986).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from July 4, 2022, to 
July 16, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the DRG originally billed. The Plan denied your request. The Plan says the medical 
records do not support the billed DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 (Sepsis, unspecified organism) and N17.0 
(acute kidney failure with tubular necrosis). 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not 
support that the inpatient care is payable as billed. Our physician reviewer found that there was no clinical or 
laboratory evidence of sepsis. In addition, the documentation did not support the diagnosis of acute tubular 
necrosis as the presence of non-hyaline casts, urine sodium, or fractional excretion of sodium (FENa) level 
were not reported and there was not no renal biopsy reported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from July 4, 2022, to July 16, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a CardioMEMS device (33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that a kyphoplasty is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says a kyphoplasty is 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 pre-approve a kyphoplasty. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no trial of bracing for fracture care. More conservative measures are needed to demonstrate 
the medical necessity of the requested service. 
 
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 procedure (22514).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the medical services (28400 and 99285) provided May 18, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 28400 is closed treatment of calcaneal fracture; without manipulation. The definition of code 99285 is 
emergency department visit for the evaluation and management of a patient, which requires a medically 
appropriate history and/or examination and high level of medical decision making. 
 
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 found the documentation supports 
procedure note 28400. For code 99285, the records support there was a comprehensive history and exam and 
there was a high complexity level of medical decision making. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the medical services (28400 and 99285) provided May 18, 2023.  
 
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 the urine polymerase chain reaction (PCR) panel provided on 
April 10, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on April 10, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy home health services and 
3 social worker home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the additional visits are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our physician 
reviewer found Clinical documentation shows that patient is ambulating without assistive device with improved 
time up and go score thus all appropriate home health physical therapy goals have been met. Additionally, 
home health social worker visits are not a Medicare approved service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy home health services and 3 social worker home 
health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on June 28, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that this claim should be reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on June 28, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 26, 2023, billed with 
procedure code G2212. 
 
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 the billed code is an add on code that was billed 
without an appropriate primary procedure. 
 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 the 
practitioner services provided is an add-on code and has not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for practitioner services provided on April 26, 2023, billed with procedure code 
G2212.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services described by code 90832 
performed on June 13, 2023. 
 You asked the Plan to pay for 90832. You say that 90832 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 90832 is denied because record does not include 
contact or attempted contact with the attending or primary care physician as required. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 90832 have not been met. Specifically, the record does not include documentation of a consultation 
or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. There is also 
no referral in the case file or specific documentation in the medical record stating the enrollee was referred by 
the primary or attending physician. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy services described by code 90832 performed on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0230) provided on June 13, 2023, to 
July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay these charges. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 13, 2023. One 
intraoral image was approved and paid. The remaining two additional intraoral images have been correctly denied. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0230) provided on 
June 13, 2023, to July 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service June 19, 
2023, to June 26, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim processed as out-of-network is 
incorrect. The Plan denied your request. The Plan says an incorrect type of bill was submitted. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was submitted with type of bill code 321. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health care billed for dates of service June 19, 2023, to June 26, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service March 22, 
2023, to May 23, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service March 22, 2023, to May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit coded as G0463 billed on 
April 26, 2023. 
 
You asked the Plan to pay for G0463. You say that G0463 should be paid as billed because it is a billable and 
payable code and complies with billing requirements. The Plan denied your request. The Plan says G0463 is 
denied because no medical records were provided for April 26, 2023, despite multiple requests. Therefore, the 
Plan is unable to determine if coverage criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. We confirmed that the case file does not contain any medical records 
for the billed date of service, April 26, 2023, to support the billing of code G0463. Based on this information, 
we decided that there is insufficient information in the record to determine if Medicare rules for coverage of 
G0463 have been met. Therefore, we decided that the Plan does not have to pay for the hospital outpatient 
clinic visit coded as G0463 billed on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that you disagree with the denial and 
have attached medical records to support medical necessity. The Plan denied your request. The Plan says a 
review of the current medical literature does not support this procedure to be reasonable and 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 pre-approve a peripheral nerve stimulator. 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 chronic back pain and spinal stenosis. She has tried 
physical therapy, a home exercise program, chiropractic care and acupuncture. She is currently taking 
Hydrocodone/Acetaminophen. She had a psychological evaluation which cleared for insertion of peripheral 
nerve stimulator. This is considered experimental therapy for back pain. Therefore, the request is deemed not 
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 a peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array; peripheral 
nerve (excludes sacral nerve) (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing system (E2301), a shoulder 
harness/straps or chest strap (E0960), medial thigh support, any type, including fixed mounting hardware 
(E0957) and a manual swingaway, retractable, or removable mounting hardware for joystick, other control 
interface or positioning accessory (E1028). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the provider believes that the requested 
power standing features and a knee block hardware is medically necessary and beneficial to the enrollee. The 
Plan denied your request. The Plan says a power standing feature is not primarily medical in nature. It is not 
covered by the health plan. It is considered a convenience item. Accessories needed only for use with a power 
standing feature, knee block, brackets for knee block and chest support for standing, 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 pre-approve wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the power standing feature, shoulder harness/straps or chest strap and the medial 
thigh support are statutorily non-covered as they are not primarily medical in nature. The LCA also states: 
"swingaway, retractable, or removable hardware (E1028) is non-covered if the primary indication for its use is 
to allow the enrollee to move close to desks or other surfaces." Provided records do not clarify the necessity of 
the swing away, retractable or removable mounting hardware for the joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power standing system (E2301), a shoulder harness/straps or chest strap 
(E0960), medial thigh support, any type, including fixed mounting hardware (E0957) and a manual swingaway, 
retractable, or removable mounting hardware for joystick, other control interface or positioning accessory 
(E1028).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service July 14, 
2023.   
You asked the Plan to pay for procedure code 88374. 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 88374 is 5. The MAI value for this code is 3. You billed 8 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 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service July 14, 2023.