Persius/hicric huggingface dataset:
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. You say that 
the requested group 3 power wheelchair is medically necessary to prevent further injury and to maintain the 
enrollee's safety. 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 requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy and therapeutic 
radiology simulation-aided field setting. 
 
You asked the Plan to pre-approve radiation services. You say that you are appealing the denial of these 
services. The Plan denied your request. The Plan says that the treatment does not meet requirements for 
approval. 
 
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 radiation services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no compelling reasons offered for why stereotactic radiation therapy 
(SRT) would be needed over more standard approaches of radiation delivery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve high dose rate electronic brachytherapy and therapeutic radiology simulation-aided 
field setting.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the medication. Our physician reviewer 
found the use of Prolia without concomitant use of supplemental calcium and vitamin D is not supported by 
one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS)-approved medical journal. The use of Prolia without concomitant use of supplemental calcium 
and vitamin D is not indicated, supported, or recommended in any of the compendia. The use of Prolia without 
concomitant use of supplemental calcium and vitamin D does not meet Medicare criteria for safe and effective and otherwise reasonable and necessary for this enrollee.  
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left shoulder balloon spacer (C9781 or 29999). 
 
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 considering the weak evidence-based support in the current literature, there 
are no extenuating clinical circumstances in this case that would support proceeding with a shoulder balloon 
spacer procedure in this one time in this enrollee with irreparable rotator cuff repair.  
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to corroborate that the requested procedure is as safe/effective as the standard shoulder procedures in this clinical 
scenario. No compelling rationale is presented, or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested left shoulder balloon spacer, in this case, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the left shoulder balloon spacer (C9781 or 29999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (82306) provided on November 10, 2022. 
 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 coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, Vitamin testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab 
testing (82306) provided on November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (87631-59), 
noninvasive ear or pulse oximetry for oxygen saturation (94761-59), additional supplies (99072-59) provided 
on September 20, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of 99072 have not been met. Procedure 94761 has a status indicator of T on the CMS National 
Physician Fee Schedule (NPFS) Relative Value (RVU) file. This means this service is always bundled into 
another payable physician service, 94664, billed the same day by the same provider. For code 87631, all MDT 
services must include an identifier as additional claim documentation. Test providers must receive an identifier 
specific to the applicable test and submit the test assigned identifier with the claim for reimbursement. The 
assigned identifier will provide a crosswalk between the test's associated detail information on file and the 
submitted claim detail line(s) required to adjudicate each test's claim. The MolDX Program requires 
laboratories to obtain a test-specific identifier - a DEX Z-Code -that is unique to the laboratory's specific test 
(i.e., the unique test identifier establishes a link to the specific test performed). When reported in conjunction 
with the appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System 
(HCPCS) code, the identifier allows payers to determine the exact, test that has been performed, facilitating 
the process of making pricing and/or coverage determinations. 
 
We looked at 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 
infectious agent detection by nucleic acid (87631-59), noninvasive ear or pulse oximetry for oxygen saturation 
(94761-59), additional supplies (99072-59) provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs this to keep carbon dioxide levels 
within normal range. The Plan denied your request. The Plan says there is no documentation that bilevel 
positive airway pressure (BiPAP) therapy has been found ineffective. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
December 21, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. The Plan denied your request. The Plan says 
payment for codes 87481 and 87653 is bundled into payment for code 87801. 
 
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 87481 and 87653 are column II codes to column I code 87801; 
however, 87481 and 87653 were both 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 procedure codes 87481 and 87653. Our reviewer says that 
the criteria for coverage has not been met. Our reviewer found that the medical records do not support the use 
of procedure codes 87481 XU and 87653 XU to be billed separate from all-inclusive 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481 and 87653 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service December 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (87631-59) and 
additional supplies (99072-59) provided on August 29, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
Procedure 94761 has a status indicator of T on the CMS National Physician Fee Schedule (NPFS) 
Relative Value (RVU) file. This means this service is always bundled into another payable physician service, 
94664, billed the same day by the same provider. 
 
For code 87631, all MDT services must include an identifier as additional claim documentation. Test providers 
must receive an identifier specific to the applicable test and submit the test assigned identifier with the claim 
for reimbursement. The assigned identifier will provide a crosswalk between the test's associated detail 
information on file and the submitted claim detail line(s) required to adjudicate each test's claim. The MolDX 
Program requires laboratories to obtain a test-specific identifier - a DEX Z-Code -that is unique to the 
laboratory's specific test (i.e., the unique test identifier establishes a link to the specific test performed). When 
reported in conjunction with the appropriate Current Procedural Terminology (CPT)/Healthcare Common 
Procedure Coding System (HCPCS) code, the identifier allows payers to determine the exact, test that has 
been performed, facilitating the process of making pricing and/or coverage determinations. 
 
We looked at 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 
infectious agent detection by nucleic acid (87631-59) and additional supplies (99072-59) provided on August 
29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 17, 2023, by an out-
of-network (OON) provider at the in-network rate.  
 
You asked the Plan to pay for OON imaging services at the in-network rate. You say that the enrollee could not 
choose a different provider The Plan denied your request. The Plan says this processed correctly. 
 
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 at the in-network rate or cost-sharing 
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 imaging services provided on January 17, 2023, 
by an out-of-network (OON) provider at the in-network rate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 36000 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics (87900) provided on February 2, 2023. 
 
You asked the Plan to pre-approve the laboratory service. You say that the claim should be paid. The Plan 
denied your request. The Plan says the procedure code is not valid for reimbursement. The code 87900 was not 
appropriate from the ordering and servicing providers, and they are not appropriate for the diagnosis code 
billed, R30.0. 
 
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 laboratory service. 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 code 89700 is not appropriate from the ordering 
and servicing providers. The genotypic bioinformatics was not appropriate for the diagnosis code billed, R30.0. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve infectious agent drug susceptibility phenotype prediction using regularly updated 
genotypic bioinformatics (87900) provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99212) in place of service (POS) 21 provided 
on May 5, 2022. 
 
You asked the Plan to pay for code 99212 in POS 21. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says the code used is not valid for payment. 
 
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 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 code 99212 in POS 21. Our reviewer says that the service is 
not supported. Our reviewer found medical records do not support procedure code 99212 to be billed with POS 
21. If the enrollee was inpatient the evaluation and management (E/M) needs to reflect that. Code 99212 is an 
outpatient setting E/M. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99212 in POS 21 have not been met. Therefore, we decided that the Plan 
does not have to pay for an office visit (99212) in place of service (POS) 21 provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the medical services provided in Mexico 
between August 5, 2022, and August 8, 2022.  
 
You asked the Plan to provide reimbursement for the medical services. You say that you were diagnosed with 
COVID in July 2022 and left the country to receive medical care because you were afraid for your life. You 
believe that you should be reimbursed for this care. The Plan denied your request. The Plan says the services 
were not emergency services and were not unforeseen. You elected to receive care for your condition outside 
of the United States. The Plan does not cover out-of-country care that is not emergent or urgently needed.  
 
The Plan must follow Medicare rules. Medicare rules say that payment generally cannot be made for medical 
services received outside of the United States. Your Plan provides a supplemental benefit which is limited to 
emergency and urgently needed services.    
We looked at the file and Medicare rules. The evidence in the file and your appeal letter indicate that you 
elected to leave the country after being diagnosed with COVID-19. There was no emergency care rendered as 
the records show you were not hospitalized and were prescribed outpatient medications and vitamin injections. 
There is no evidence that your medical condition was life-threatening. The services cannot be considered 
urgently needed because the need for the services was foreseen prior to leaving the service area. Your Plan 
does not provide coverage for services you chose to receive outside of the United States. Based on this 
information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, 
we decided that the Plan does not have to provide reimbursement for the medical services provided in Mexico 
between August 5, 2022, and August 8, 2022.
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 are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
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 the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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.