Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 for date of 
service September 23, 2022. 
 
You asked the Plan to pay for the laboratory services billed with code 81479. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
billed with code 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with code 81479 for date of service September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections (64454 and J3301) provided on October 4, 
2022. 
 
You asked the Plan to pay for the injections. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the injections have not been met. Review of the file shows that the 
diagnosis codes billed on the claim are M17.0- bilateral primary osteoarthritis of knee and I10- essential 
(primary) hypertension. The diagnosis codes billed are not on the LCD; therefore, the enrollee does not meet 
criteria for coverage for this service. Therefore, we decided that the Plan does not have to pay for the injections 
(64454 and J3301) provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96127 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 96127. You say that you billed code 96127 with a 59 modifier to 
show that it was separately identifiable. The Plan denied your request. The Plan says payment for code 96127 
is bundled into payment for code 99406. 
 
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 96127 is a column II code to column I code 99406 with a modifier indicator of 0. This means that the presence of the 
59 modifier does not make the code separately payable. The column II code is therefore not payable. Based on 
the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 96127 billed for date of service July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232) provided on August 9, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, the subsequent hospital care 
is included in the global surgery package of procedure code 44143. A modifier was not used to denote a 
separate and unrelated service. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (99232) provided on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with battery. 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair with battery. You say that you need 
this item. The Plan denied your request. The Plan says you do not meet Medicare guidelines for a power 
mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 standard power wheelchair 
with battery. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is 
no evidence you require a powered device to complete mobility assisted activities in the home. you have 
limited endurance but can stand and walk. 
 
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 group 2 standard power wheelchair with battery have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with battery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0427-EH) provided on April 17, 
2022. 
 
You asked the Plan to pay for ambulance transport. You say that the enrollee was transported twice on the date 
in question. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 21, 2022. Comparison of the two claims shows these are exact duplicates.  
 There is no evidence presented to support that the billed items/services were provided twice on the same date, 
as the records provided only detail one transport. Based on this information, we decided that the Medicare rules 
for ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance transportation (A0427-EH) provided on April 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64624 billed for date of service December 
21, 2022. 
 You asked the Plan to pay for procedure code 64624. You say that this is a reimbursable service and it was 
medically necessary. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64624 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64624 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64624 billed for date of service December 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 2, 2022, billed with 
code 95955-26-59. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 95955-26-59 is Electroencephalogram (EEG) during non-
intracranial surgery. 
 
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 imaging services provided. Our reviewer says that documentation does not support the billed code Our reviewer found the procedure report documents 
neuromonitoring services provided for incision and drainage, wound vacuum placement. For procedure code 
95955, the provider used electroencephalographic monitoring of a patient during non-intracranial surgery like 
cardiac surgery or carotid stenting. The procedure report does not include documentation to support the code 
description, and therefore cannot be verified. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on August 2, 2022, billed with code 95955-26-59.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve the medication. You say that this medication is necessary for the enrollee. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and consultations (97032, 97110, 97112, 
97140, 97161, 97162, 97163, 97164, 97530) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and consultations. You say that the enrollee needs to get 
services from an OON because there is no one in network for this specialty near the enrollee's area. The 
enrollee was referred for pelvic floor physical therapy due to stress urinary incontinence. The Plan denied your 
request. The Plan says the enrollee must use these network providers for most services. There are times when 
the health plan will cover out-of-network services. This is for emergency services and routine travel dialysis. 
The requested service is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits and consultations (97032, 97110, 97112, 97140, 97161, 97162, 97163, 97164, 97530) to be 
provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. 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 Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Neulasta is not FDA-
approved for the enrollees diagnosis. The enrollee is not neutropenic and for metastatic disease there would be 
a dose reduction. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are not ready for discharge to the community at 
this time you need continued skilled services such as physical and occupational therapy so you can continue to 
meet his goals to discharge safely. The Plan denied your request. The Plan says your request does not meet 
guidelines because you no longer require skilled services on a daily inpatient basis and the continuation of 
skilled nursing facility is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (81551) provided on January 17, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81551 is not supported in the medical record. Specifically, the claim was billed with 
two diagnosis codes that cannot be billed together (D29.1 and N40.1). Based on this information, we decided 
that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does 
not have to pay for lab testing (81551) provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of a peripheral nerve (64640). 
 
You asked the Plan to pre-approve destruction of a peripheral nerve. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 destruction of a peripheral nerve. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review has determined that the use of the Iovera system, rather than 
standard methods, for pain management status post (s/p) total knee replacement (TKR), is not found to be 
reasonable and medically 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 destruction of a peripheral nerve have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction of a peripheral nerve (64640).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product (VIA Disc procedure). 
 
You asked the Plan to pre-approve VIA Disc procedure. You say that the requested procedure is minimally 
invasive. You say that this procedure is medically necessary for the enrollee's condition. You also say that this 
should be approved. The Plan denied your request. The Plan says the requested procedure 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 VIA Disc procedure. Our reviewer says 
that the requested VIA Disc procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient high-quality evidence to support this request to treat the enrollee's back pain. Therefore, the reviewer found that the requested VIA Disc procedure is not medically reasonable or 
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 VIA Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product (VIA 
Disc procedure).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder Detect test provided on June 16, 2022. 
 
You asked the Plan to pay for the CXbladder Detect test. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage is reaffirmed for CxBladder 
testing. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder Detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXbladder Detect test provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy (0394T) and therapeutic 
radiology simulation-aided field setting (77280, 77290). 
 
You asked the Plan to pre-approve electronic brachytherapy and therapeutic radiology simulation. You say that 
due to the enrollee's Basal cell carcinoma of skin of other parts of face, it is medically necessary. The enrollee 
needs the radiation instead of having surgery. The Plan denied your request. The Plan says research studies 
have found a lack of proof that routine use of the requested type of treatment would improve the outcome for 
the enrollee's cancer type. It has not been shown that the enrollee's cancer type has responded well to the 
requested type of treatment. 
 
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 electronic brachytherapy and 
therapeutic radiology simulation. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found based on the community 
standards of care, this type of skin cancer is not usually treated with electronic brachytherapy (0394T) and 
therapeutic radiology simulation-aided field setting. The medical literature does not show that enrollees 
responded well to the requested type of treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy and therapeutic radiology simulation have not been 
met. Therefore, we decided that the Plan does not have to pre-approve electronic brachytherapy (0394T) and 
therapeutic radiology simulation-aided field setting (77280, 77290).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 9, 2022. 
 
You asked the Plan to pay for the lab services. 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 December 9, 2022.