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

 
We decided that the Plan does not have to pre-approve stab phlebectomy of varicose veins. 
 You asked the Plan to pre-approve stab phlebectomy of varicose veins. You say that stab phlebectomy of 
varicose veins is medically necessary. The Plan denied your request. The Plan says the requested stab 
phlebectomy of varicose veins does not meet the Medicare LCD coverage criteria. Saphenous reflux is present. 
Of note, varicosities need to be greater than 4mm in diameter to qualify for phlebectomy and the ultrasound 
provided does not detail the size of varicosities being treated. 
 
The Plan follows Medicare rules. Medicare rules say that stab phlebectomy of varicose veins is covered when 
the criteria listed in the Medicare rules section of this decision are met. 
 
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 stab phlebectomy of varicose veins. 
Our reviewer says that the requested stab phlebectomy of varicose veins is not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has varicose 
veins with untreated saphenous reflux. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy of varicose veins have not been met. Therefore, we decided 
that the Plan does not have to pre-approve stab phlebectomy of varicose veins.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2023, billed with 
codes 81226, 81240, 81241, 81306, 81328, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 14, 2023, billed with codes 81226, 81240, 81241, 81306, 81328, and 81335.
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 meets the full criteria for an IRF 
admission, and you would like reconsideration based on the records submitted. The Plan denied your request. 
The Plan says the enrollee does not meet all the requirements for admission to an IRF.  
 
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 rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that they would meet criteria for admission to an IRF.  There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status.  The 
enrollee can receive further services at a lower 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0481 and 80307) provided from February 
6, 2023, through February 23, 2023. 
 
You asked the Plan to pay for the drug testing. You say that you are requesting reconsideration for services 
advising the coding department has reviewed the services and determined that the claim is coded correctly. The 
Plan denied your request. The Plan says the diagnosis codes should not be reported together which is based on 
the Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The diagnosis codes associated 
to Z79.891 and F11.20, should not be reported together. The billed service has been denied because it was 
reported with one or more diagnosis code pairs that are subject to an Excludes1 note. Based on this 
information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug testing (G0481 and 80307) provided from February 6, 
2023, through February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0482) provided March 10, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
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. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the drug testing have been met. The 
current documentation does not include the appropriate method of testing for the billed code. In order to 
validate services billed the appropriate method of testing should be documented within the medical record. 
Therefore, the billed service cannot be verified. Therefore, we decided that the Plan does not have to pay for 
the drug testing (G0482) provided March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple 
power option (K0862) and additional items and accessories (codes E2311, E2313, E2377, E0955, E1002, 
E1012, E1028, E2361, and E2608). 
 
You asked the Plan to pre-approve a group 3 heavy duty power wheelchair with multiple power option and 
additional items and accessories. You say that the enrollee is in great need of the requested power chair. You 
also say that the chair is not only medically necessary at this point in time, but it will also be needed over the 
next several years as the enrollee's condition likely progresses further. The Plan denied your request. The Plan 
says the enrollee does not have medical need for multiple power options included with a K0862 Group 3 power 
wheelchair. The Plan also says an electronic connection, harness, and expandable controller cannot be covered 
as it is not medically necessary to control the three requested power options through the joystick (drive 
interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as 
code K0862) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
 
 
 
 
 
 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 3 heavy duty power wheelchair 
with multiple power option and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found the enrollee requires a power wheelchair for 
mobility and accomplishing their daily activities. However, the clinical documentation is insufficient why a 
lower-level power wheelchair would not meet their needs versus a group 3 power wheelchair. Our reviewer 
found that there is inadequate clinical documentation regarding why they require power tilt and cannot 
adequately perform pressure relief. There is no history of skin breakdown, and the enrollee is modified 
independent to independent with transfers and all their daily activities. Our physician reviewer also found that 
the enrollee has good sitting balance. Group 3 power wheelchair bases are typically used in patients with 
paralysis who are dependent for pressure relief and transfers. 
 
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 3 heavy duty power wheelchair with multiple power option and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 heavy duty power wheelchair with multiple power option (K0862) and additional items and 
accessories (codes E2311, E2313, E2377, E0955, E1002, E1012, E1028, E2361, and E2608).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve template to guide implant placement (D6190), implant 
placement (D6010), second surgery to uncover implant (D6011) implant supported crown (D6065), 
prefabricated abutment (D6056) and a pontic (D6245). 
 
You asked the Plan to pre-approve these dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says procedure code D6065 is the incorrect code for the service requested. The 
Plan also says the additional dental services requested cannot be approved because they are secondary to a 
denied primary service. 
 
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, the requested items or services are not 
among those covered under this benefit. Specifically, D6065 is the incorrect code for the service being 
requested and the additional services cannot be approved when the primary service is not approved Therefore, 
we decided that the Plan does not have to pre-approve template to guide implant placement (D6190), implant 
placement (D6010), second surgery to uncover implant (D6011) implant supported crown (D6065), 
prefabricated abutment (D6056) and a pontic (D6245).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 6, 2023, billed with 
codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-59, 81306-59, 81328-59, 
81335-59, 81479-GY 59, 81238-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have attached additional documents 
to support that claim. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 6, 2023, billed with codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-59, 
81306-59, 81328-59, 81335-59, 81479-GY 59, 81238-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1852) and suspension sleeve (L2397), 
purchased on June 19, 2023. 
 
You asked the Plan to pay for the knee brace and suspension sleeve. You say that the items should be covered. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The medical records submitted to do indicate the items were needed or ordered. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the knee brace (L1852) and suspension sleeve (L2397), 
purchased on June 19, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary.  
 
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 patients nursing, medical, and rehabilitation may require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is unclear if the patient 
can tolerate and benefit from the intensity of therapies provided in an acute inpatient rehabilitation 
facility. Therefore, the acute inpatient rehabilitation admission is not 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (80053, 80061, 82550, 84439, 84443 and 84480) 
billed for date of service May 23, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that the documentation supports that these 
lab tests were performed, but there is no explanation of why these tests were reported by multiple providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no evidence to support that these services 
were reported by multiple providers or facilities. The Plan has not substantiated their denial in this case. 
Therefore, we decided that the Plan has to pay for laboratory services (80053, 80061, 82550, 84439, 84443 and 
84480) billed for date of service May 23, 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: 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 you need inpatient therapy before returning home. 
The Plan denied your request. The Plan says your records do not show that your rehab needs are complex. The 
Plan says services may be provided at a lower level of care.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a colonoscopy with removal of polyps 
provided on November 29, 2022. 
 
You asked the Plan to reduce the copayment for a colonoscopy with removal of polyps. You say that you think 
that the copayment should be lower. 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 $300 
copayment for each Medicare-covered outpatient hospital visit. 
 
You have been asked to pay a $300 copayment for a colonoscopy with removal of polyps. This item/service 
falls within the each Medicare-covered outpatient hospital visit 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 reduce the copayment for a colonoscopy with removal of polyps provided on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 24, 2023, billed with 
codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 81321-90, 81351- 90, 81209-
90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90GYx3, 81317-90. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have attached additional documents 
to support the claim. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 24, 2023, billed with codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 
81321-90, 81351- 90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90GYx3, 81317-90.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service May 22, 
2023. 
 You asked the Plan to pay for procedure code 93010. You say that the enrollee had multiple examinations. The 
Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 62270. 
 
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 93010 
is a column II code to column I code 62270. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 93010 billed for date of service May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01942 for date of service April 24, 2023. 
 
You asked the Plan to pay for procedure code 01942. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that M48.56XA has an Excludes1 note in relation to M80.08XA. This means 
that the two diagnosis codes cannot be reported together. Based on this information, we decided that the 
Medicare billing rules for procedure code 01942 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 01942 for date of service April 24, 2023.