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

 
We decided that the Plan does not have to waive the copayment for an in-network high frequency airway 
clearing system provided from March 14, 2023, to April 14, 2023. 
 
You asked the Plan to waive the copayment for an in-network high frequency airway clearing system. You say 
that you were told by the plan that there was an incorrect billing code, and you should not owe this much. 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 20% 
coinsurance for durable medical equipment (DME) and related services.  
 
The allowed amount of this item is $1413.84, resulting in a coinsurance amount of $282.77 ($1413.84 x 20% = 
$282.77). There were two claims, resulting in a $575.54 total ($282.77 x 2 = $575.54). You have been asked to pay a $575.54 total coinsurance for an in-network high frequency airway clearing 
system. This item/service falls within the durable medical equipment (DME) and related 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 to waive the copayment for an in-network high frequency airway clearing 
system provided from March 14, 2023, to April 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on January 25, 2023, to January 26, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
were admitted to the hospital, therefore, you should not have to pay this 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an in-network emergency room (ER) visit. This item/service 
falls within the emergency care 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 to waive the copayment for 
an in-network emergency room (ER) visit provided on January 25, 2023, to January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote patient monitoring provided on March 31, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the remote patient monitoring. You say that it was medically necessary for the 
provider to perform this service. The Plan denied your request. The Plan says enrollees must receive their care 
from a network provider. 
 
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 had network providers 
available who could have provided the item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the remote patient monitoring provided on March 31, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 22, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says it was decided to approve payment for some codes. However, the 
enrollee does not have the required personal history of cancer to approve the other codes. 
 
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 
March 22, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 
and 81334.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each dialysis procedure provided on 
February 02, 2023, to February 28, 2023. 
 
You asked the Plan to waive the coinsurance for each dialysis procedure. You say that you cannot afford the 
cost share. 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 20% 
coinsurance for services to treat kidney disease.  
You have been asked to pay 20% coinsurance for each dialysis procedure. This item/service falls within the 
services to treat kidney disease 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. The amount you owe for each dialysis procedure is $58.80 ($294 allowed 
amount x 20% = $58.80). The total amount you owe is $705.60 ($58.80 coinsurance x 12 procedures = 
$705.60). Therefore, we decided that the Plan does not have to waive the coinsurance for each dialysis 
procedure provided on February 02, 2023, to February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 09, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that this patient is in a facility, and you depend 
upon the facility staff for any verification or prior authorization. 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 a nursing facility visit 
provided on March 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a center mount foot platform (K0108). 
 
You asked the Plan to pre-approve a center mount foot platform. The Plan denied your request. The Plan says 
the center mount platform does not meet the Medicare criteria for durable medical equipment. The Plan also 
says this item still does not meet the coverage criteria. 
 
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 center mount foot platform. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record does not reveal a medical necessity for the device. Our reviewer also 
found that none of the professional evaluations indicate a need for the accessory. 
 
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 center mount foot platform have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a center mount foot platform (K0108).
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 approved power options on this wheelchair (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 has 5 out of 5 strength in their 
upper extremities. Our reviewer also found that the enrollee has sufficient strength and function in their upper 
extremities to manage standard power drives. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 Kyphoplasty (22513, C1062, and 22510). 
 
You asked the Plan to pre-approve T12 Kyphoplasty (22513, C1062, and 22510). You say that the requested 
T12 Kyphoplasty is medically necessary.  The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested T12 Kyphoplasty. 
 
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 T12 Kyphoplasty (22513, C1062, and 
22510). Our reviewer says that the enrollee does not meet criteria for the requested T12 Kyphoplasty. Our 
physician reviewer found there is no trial of fracture bracing. More conservative measures are needed before 
considering this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 Kyphoplasty (22513, C1062, and 22510) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve T12 Kyphoplasty (22513, C1062, and 22510).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has 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 that although there are three approved power options on this wheelchair 
(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 if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 considered medically reasonable 
and necessary in this case. Our physician reviewer found the complexity of the enrollee's seating and 
positioning needs necessitates a more complex group 3 power wheelchair base. The expandable controller with 
harness and electronic connection are necessary to operate the group 3 power wheelchair base and the three 
power options via a joystick. Our reviewer also found that these components are required to operate 3 or more 
power options on a group 3 power wheelchair. 
 
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 been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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 procedure code 99205 for date of service  
 
You asked the Plan to pay for procedure code 99205. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not supported. 
 
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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, the documentation did not 
include the time spent on this service. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99205 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99205 for date of service
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve the home health visits. You say that you still need registered nursing care 
for your wound dressing. You also say that you are unable to do the wound dressing yourself, there is hardware 
showing from a previous surgery, and you do not have family members who can help you with the wound 
dressing. The Plan denied your request. The Plan says the services 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 the home health visits. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you are noted 
to have no active infection at your surgical site. Our reviewer also found that your right sided ankle fracture 
and wound are chronic in nature at this point, and the wound care would not be considered complicated enough 
to warrant continued skilled nursing care at this point. 
 
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 home health visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health skilled nursing visits (G0299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 
87801 billed for date of service February 28, 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 covered. 
 
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 codes 
87150, 87481, 87641, 87653, and 87798 are column II codes to column I code 87801. This claim has not been 
billed with an appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate and 
distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been met.  
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT 87801 is not supported in the medical record. Specifically, there is no documentation to 
support the individual organisms billed for the code. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 
87798, and 87801 billed for date of service February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records report that 
the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
(medical notes do not dispute this); this is a modality that could be provided by a bilevel positive airway 
pressure (BiPAP) device with AVAPS and a back-up rate. Provided records do not document trial and failure 
of a BiPAP device with AVAPS and a back-up rate. 
 
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 for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that you require the second set of 
ablations is for pain management in the left and right side of your spine. The Plan denied your request. The 
Plan says radiofrequency ablation to three levels of the spine 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 radiofrequency ablation. Our reviewer 
says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that the national 
coverage determination (NCD) and LCD limits radiofrequency ablation of the medial branches to two levels 
bilaterally per session. The request exceeds this limit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single axis, fluid swing and stance phase control 
(L5828), a stance flexion feature, adjustable (L5845), a fluid stance extension, (L5848) and a microprocessor 
control feature, swing and stance phase (L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that you have reviewed Medicare's policy and you 
believe you are entitled to the approval of the service codes requested. The Plan denied your request. The Plan 
says the requested prosthetic parts and computerized knee exceeds your needs. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are quite active negotiating a significant number of barriers. You were using a walker prior 
to amputation, and you continue to use a walker. You are a standard K-3 ambulator and do not require the 
advanced computer knee or endoskeleton additions to meet your mobility needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single axis, fluid swing and stance phase control (L5828), a stance flexion feature, 
adjustable (L5845), a fluid stance extension, (L5848) and a microprocessor control feature, swing and stance 
phase (L5856).