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

 
We decided that the Plan does not have to pay for the laboratory testing provided October 5, 2023, billed with 
codes 87500-59, 87641-59, 87798 x 13, G0452-26, 87481-59, 87651-59, 87653-59. 
 
You asked the Plan to pay for the laboratory testing. You say that you are an independent diagnostic laboratory 
that tests pathology, medication management and toxicology samples sent from clinics and providers for 
patients they have determined require such testing. 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. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory testing provided October 5, 2023, billed with codes 87500-59, 
87641-59, 87798 x 13, G0452-26, 87481-59, 87651-59, 87653-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided 
from May 19, 2023, to June 8, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump (E0218). You say that this item was 
medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) is 
not covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump (E0218) have not been met. Therefore, we decided that the 
Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided from May 19, 2023, to 
June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two abutments. We decided that the Plan does not have to pre-
approve the implant/abutment supported denture and the two additional abutments. 
 
You asked the Plan to pre-approve the implant supported denture (D6110) and prefabricated abutments 
(D6056). You say that this is medically necessary. The Plan says that the implant supported/abutment denture is not a covered service, and the prefabricated abutments are not covered since they are related to a non-
covered service. 
 
We decided that the Plan has to pre- approve two prefabricated abutments.  
 
The Plan offers a dental benefit in excess of Medicare coverage. The Plans dental coverage clearly states that 
two of code D6051, D6056 or D6057 are covered every 12 months. Therefore, we decided that the Plan has to 
pre-approve two abutments.  
 
We also decided that the Plan does not have to pre- the implant supported denture and the two 
additional abutments. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the implant/abutment support denture 
(D6110) requested is not listed as a covered benefit. In addition, only two of code D6051, D6056 or D6057 are 
covered every 12 months. Two abutments have been approved and the remaining two cannot be covered. 
Therefore, we decided that the Plan does not have to pre-approve the implant supported denture and the two 
additional abutments. 
 
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 anesthesia for percutaneous image-guided neuromodulation 
or intravertebral procedures rendered on April 6, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says age related osteoporosis with current path fracture is not listed as a medically necessary 
diagnosis. 
 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the diagnostic coding does not support the need for MAC without further explanation of an 
extraordinary issue, such as morbid obesity or psychiatric disorder. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures 
rendered on April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services before discharging 
home. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViaDisc injection (0627T). 
 
You asked the Plan to pre-approve a ViaDisc injection. 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 ViaDisc injection. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested service is considered to be experimental/investigational therapy. 
 
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 ViaDisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ViaDisc injection (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee brace (knee orthosis) (L1851). 
 
You asked the Plan to pre-approve the orthosis. You say that the orthosis is medically necessary. The Plan 
denied your request. The Plan says the orthosis is not 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 the orthosis. Our physician reviewer 
found criteria have not been met per L33318. The documentation does reveal the enrollee is ambulatory. The 
documentation does not reveal a recent injury or surgery to the knee or evidence of objective knee instability 
on a physical examination. 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 orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the knee brace (knee orthosis) (L1851).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75716-26-59 provided September 25, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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. 
 
In this case, we have confirmed that code 75716 is a column II code to column I code 93456; however, 75716 
was billed with a modifier.  
 
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 service. Our reviewer found the medical documentation 
does not support the use of the additional code 75716 to be billed with primary code 93456, the services within 
75716 are included in the procedure 93456 and are not able to 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 75716-26-59 provided September 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 28, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not authorized. 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 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 provided on June 28, 2023, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystourethroscopy provided on August 24, 2023. 
 
You asked the Plan to pay for a cystourethroscopy. You say that this service is supported in the records. 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 cystourethroscopy 
provided on August 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health (HH) physical therapy (PT) visits (G0151 
X 4). 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the Health 
Plans denial should be upheld. The enrollee does not have documented HH PT needs. The enrollee appears to 
be at her baseline. As such, the requested HH PT is not medically necessary or reasonable. 
 
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 home health (HH) physical therapy (PT) visits (G0151 X 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for post head injury or post stroke hemiplegia. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's  stroke condition or in widespread use for this patient's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this 
patient. There is insufficient evidence in the literature that this device will increase  participation in bimanual 
activities. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro orthotic device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopic procedure provided on 
April 20, 2023. 
 
You asked the Plan to waive the copayment for the endoscopic procedure. You say that the procedure was 
medically necessary. 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 $275 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $275 copayment for the endoscopic procedure. This item/service falls within the 
outpatient surgery, including services provided at ambulatory surgical centers 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 the endoscopic procedure provided on April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 12, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The genetic testing provided in this case is not covered under the 
DEX Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on September 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital inpatient discharge (99239) provided on May 24, 
2023. 
 
You asked the Plan to pay for the hospital discharge. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says the medical records submitted do not support a hospital 
discharge day management of more than 30 minutes was performed. Therefore, code 99239 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 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We asked our physician 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 hospital discharge. Our reviewer found the medical 
record includes a discharge note for date of service billed, however time spent performing service was not 
included in documentation and cannot be verified. 
 
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 hospital discharge have not been met. Therefore, we decided that the Plan 
does not have to pay for the hospital inpatient discharge (99239) provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hyperbaric oxygen under pressure, full body 
chamber, per 30-minute interval (G0277) and physician attendance and supervision of hyperbaric oxygen 
therapy, per session (99183). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 the services. Our physician reviewer 
found hyperbaric oxygen therapy (HBOT) is not reasonable. While the most recent episode of wound care was 
initiated in October of 2023, the enrollees wound is noted to be more than six years old. During that time, the 
area has been plagued by episodes of cellulitis and osteomyelitis. A November 2023, magnetic resonance 
imaging (MRI) showed extensive disease. The enrollee previously declined to have an amputation. It seems 
unlikely that HBOT is going to be beneficial in treating this chronic wound. The requested treatment is not 
reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the hyperbaric oxygen under pressure, full body chamber, per 30-minute interval (G0277) 
and physician attendance and supervision of hyperbaric oxygen therapy, per session (99183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8701). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item 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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested item is not the standard of care for the enrollee's post-polio condition. The MyoPro orthosis is not known to be effective, based on scientific evidence, professional standards and expert 
opinion, in improving health outcomes. The MyoPro orthosis is not in widespread use for the enrollee post-
polio condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
orthosis will improve the long-term outcomes for the enrollee. There is insufficient evidence in the literature 
that this device will increase participation in bimanual activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8701).