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

 
We decided that the Plan does not have to pre-approve a lightweight portable motorized/power wheelchair 
(K0012). 
 
You asked the Plan to pre-approve a lightweight portable motorized/power wheelchair. The Plan denied your 
request. The Plan says the documentation does not support the medical necessity for this service, in that the 
reason why mobility-related activities of daily living limitations cannot be resolved with a cane, rollator 
walker, or standard wheelchair are not indicated. The Plan also says the home has not been evaluated for safe 
use of the power mobility device within the home. 
 
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 lightweight portable motorized/power 
wheelchair. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer 
found the enrollee is reported to be independent in activities of daily living and instrumental activities of daily 
living. The enrollee currently uses a manual wheelchair for distances outside the home. Our reviewer also 
found that the enrollee does not require a powered device to manage MRADLs in the home. 
 
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 lightweight portable motorized/power wheelchair have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lightweight portable motorized/power 
wheelchair (K0012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2023, billed with 
code 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 
April 4, 2023, billed with code 81433.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry care for trimming of calluses provided on 
May 1, 2023. 
 
You asked the Plan to pay for the podiatry care for trimming of calluses. You say that you had a hard core in 
the center of your callus and the provider needed to use a scalpel to remove it. You say that in addition, the 
provider uses a special instrument to smooth down the callus and your toenails. The Plan denied your request. 
The Plan says according to Medicare Guidelines, the trimming of lesions (calluses) is not a covered benefit as it 
is considered routine foot care and routine foot care is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
podiatry care for trimming of calluses have not been met. Therefore, we decided that the Plan does not have to 
pay for podiatry care for trimming of calluses provided on May 1, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for 99213. We decided that the Plan does not have to pay for 77022.

You asked the Plan to pay for procedure codes 77022 and 99213 rendered on February 23, 2023.. You say that
this should be paid for. The Plan says that the denied codes remain not supported.

We decided that the Plan has to pay for 99213.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The definition of CPT 99213 is "Office or other
outpatient visit for the evaluation and management of an established patient, which requires a medically
appropriate history and/or examination and low level of medical decision making. When using time for code
selection, 20-29 minutes of total time is spent on the date of the encounter."

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 for CPT 99213. Our reviewer says that this was billed
for a low level evaluation, and should be paid. There is appropriate documentation of this code in the records,
and it was unrelated to the steroid injection of the knee done after the evaluation.

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 been met. Therefore, we decided that the Plan has to pay for
99213.

We also decided that the Plan does not have to pay for 77022.

We also decided that the Plan does not have to pay for 77022.

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 for CPT 77022. Our reviewer says that there is no
support at all in the records for CPT 77022. There is no evidence of MRI guidance for tissue ablation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 77022 have not been met. Therefore, we decided that the Plan does not have to
pay for 77022.

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Moh's micrographic surgery. 
 
You asked the Plan to pre-approve Moh's micrographic surgery. You say that this is medically necessary. The 
Plan denied your request. The Plan says records show the particular basal cell carcinoma the provider wants to 
treat with Moh's surgery is on the upper back, which is anatomic location L. There are no records that say that 
this area has been previously received radiation, is an area of a traumatic scar, an area of osteomyelitis, or an 
area of chronic inflammation. 
 
The Plan follows Medicare rules. Medicare rules say that Moh's micrographic surgery can be covered when 
specific criteria 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 Moh's micrographic surgery. Our 
reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found that the 
records do not document the basal cell carcinoma of the left lateral inferior chest is in an area of prior radiated 
skin, traumatic scar, area of osteomyelitis, area of chronic inflammation/ulceration or the patients has a genetic 
syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Moh's micrographic surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Moh's micrographic surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 24, 2023, billed with 
codes 87798, 87481, 87653, 87640, 87651, 87551, 87556, 87561, 87500, and 87641. 
 
You asked the Plan to pay for the genetic testing billed. You say that physician's send specimens for 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. 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 NGS panel testing was not billed with a single 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 January 
24, 2023, billed with codes 87798, 87481, 87653, 87640, 87651, 87551, 87556, 87561, 87500, and 87641.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee brace (L1833). 
 
You asked the Plan to pre-approve a knee brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says that the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it. 
 
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 knee brace. Our reviewer says that the 
item is medically necessary. Our physician reviewer found the enrollee has knee instability documented by 
examination and objective description of joint laxity. 
 
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 knee brace have been met. Therefore, we decided that the Plan has to pre-
approve a knee brace (L1833).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve excludes sacral nerve (64555). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array. You say that 
this is medically necessary. The Plan denied your request. The Plan says this 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 percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is insufficient evidence to 
support the use of peripheral nerve stimulation in the treatment of chronic abdominal pain. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of 
neurostimulator electrode array; peripheral nerve excludes sacral nerve (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 billed for date of service April 21, 
2023.  
 
You asked the Plan to pay for procedure code 99308. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 99308 is bundled into payment for 
code 99309. 
 
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 99308 is a column II code to column I code 99309 with a modifier indicator of 0. 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 99308 billed for date of service April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound therapy and mechanical traction therapy provided 
on January 18, 2023. 
 
You asked the Plan to pay for ultrasound therapy and mechanical traction therapy. The Plan denied your 
request. The Plan says that the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for ultrasound therapy and mechanical traction therapy provided on January 18, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the comprehensive oral evaluation (D0150) 
and the 2D oral/facial photographic image (D0350) provided on May 11, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request.   
 
The Plan says your benefit for the comprehensive oral evaluation provided has already been exhausted. 
Additionally, a 2D oral/facial photographic image is not a covered benefit under the supplemental dental 
policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation provided was exhausted on date of service  
January 19, 2023. Specifically, the Plan's contract states that one oral exam is covered every six months. You 
previously received a comprehensive oral evaluation on January 19, 2023, less than six months prior, which 
was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service at this time. 
Additionally, a 2D oral/facial photographic image is not a covered benefit under the supplemental dental 
policy. Therefore, we decided that the Plan does not have to issue reimbursement for the comprehensive oral 
evaluation (D0150) and the 2D oral/facial photographic image (D0350) provided on May 11, 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 requires extensive therapy services after 
their surgery as well as close medical supervision. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria 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 enrollee is medically stable. There are no acute rehab nursing needs documented. 
The complexity of the enrollees medical, rehab, and nursing needs does not require an acute hospital inpatient 
rehab stay with an interdisciplinary approach to rehabilitative care. The enrollees rehab needs can be safely 
provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214), a complete joint ultrasound (76881) 
and a Hyaluronan or derivative injection (J7328) provided on March 29, 2021. 
 
You asked the Plan to pay for an office visit, an ultrasound and an injection. You say that the attached medical 
records clearly document that the enrollee received examination of bilateral knees, feet, and ankles. Diagnostic 
ultrasounds were also performed on the left knee. The Plan denied your request. The Plan says code 99214 
remains not supported. The Plan also says payment for code 76881 is bundled into payment for code 20611.  
 
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 an office visit, an ultrasound and an injection. Our reviewer 
says that the service does not meet criteria for payment on claim. Our reviewer found the provider reported, 
procedure code with appended modifier 25 significant, separately identifiable evaluation and management 
(E/M) service above and beyond that associated with another procedure or service being reported by the same 
physician or other qualified health care professional (QHP) on the same date to bypass NCCI Edit with 
arthrocentesis procedures performed under ultrasonic guidance. In this case, procedure report supports a 
moderate level of decision making, however evaluation and management service provided does not support a 
significant separately identifiable evaluation and management service, as was related to the knee arthrocentesis 
procedures performed. 
 
We looked at this coder's review, the file, and Medicare rules. We have confirmed that code 76881 is a column 
II code to column I code 20611. This claim has not been billed with an appropriate modifier to bypass the edit. 
We have also confirmed that code J7328 was not billed with modifier JW or EJ. Based on this information, we 
decided that Medicare rules for coverage of an office visit, an ultrasound and an injection have not been met. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214), a complete joint ultrasound 
(76881) and a Hyaluronan or derivative injection (J7328) provided on March 29, 2021.
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 would benefit from services at an IRF to 
improve their functional mobility. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria 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 enrollee is medically stable. There are no acute rehab nursing needs documented. 
The complexity of the enrollees medical, rehab, and nursing needs does not require an acute hospital inpatient 
rehab stay with an interdisciplinary approach to rehabilitative care. The enrollees rehab needs can be safely 
provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the services are necessary. The Plan denied 
your request. The Plan says no records were received detailing why your current equipment needs to be 
replaced and how long you have had your current power scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2023, to May 20, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 23, 2023, to May 20, 2023.