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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are a diabetic and need to monitor your blood 
sugar. You also say that you have not monitored your sugar in days because of this delay. The Plan denied your 
request. The Plan says the CGM for your diabetes does not meet the guideline for approval. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
requested item is not medically necessary. Our physician reviewer found the record indicates that you have 
diabetes. The record provided does not indicate that you are being treated with insulin or have problematic 
hypoglycemia as defined by the Medicare rules. The elements of coverage 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 the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 25, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition. 
 
You asked the Plan to pre-approve enteral nutrition. You say that the oral supplement is believed to be 
completely necessary to sustain adequate nutrition. The Plan denied your request. The Plan says Medicare 
policy states enteral nutrition is covered for a beneficiary who requires feedings via an enteral access device 
and has a permanent full or partial non-function or disease of the structures that normally permit food to reach 
the small bowel; OR disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by 
the small bowel. There is no documentation this is met. 
 
The Plan follows Medicare rules. Medicare rules say that enteral nutrition 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 enteral nutrition. Our reviewer says that 
the requested enteral nutrition is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of dementia and anorexia with severe weight loss. There are no 
findings to suggest dysphagia or malabsorption. The enrollee is followed by a nutritionist who has 
recommended dietary supplements. The enrollee does not have a permanent full or partial non-function or 
disease of the structures that normally permit food to reach the small bowel; or disease that impairs digestion 
and/or absorption of an oral diet, directly or indirectly, by the small bowel. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enteral nutrition have not been met. Therefore, we decided that the Plan does 
not have to pre-approve enteral nutrition.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable bed pads (T4541). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the item should be covered. The Plan 
denied your request. The Plan says Medicare does not cover incontinence supplies because they are 
disposable, non-reusable hygiene items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve disposable bed pads (T4541).
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 a higher level of care. The Plan 
denied your request. The Plan says medical records do not support the need for an IRF admission and, the 
enrollee's needs can be provided at another 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 the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 services (87150) provided on APril 13, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 87150 is "Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed". 
 
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 services. Our reviewer says that the use of code 87150 is 
not supported by the records provided. Our reviewer found that the laboratory report does not include 
documentation of "culture typing identification". For code 87150, the records must show an analysis using amplified DNA or RNA probe technique on a previously isolated and identified organism to categorize the 
organism more specifically, such as to the taxonomic level of type. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (87150) provided on APril 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires work with physical 
and occupational therapy for core strength and transfers to return home independently. The Plan denied your 
request. The Plan says the enrollee is receiving the appropriate inpatient acute care and does not require 
transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no therapeutic advantage to LTACH transfer compared to staying in the 
current setting until ready for discharge to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (scooter) (K0800). 
 
You asked the Plan to pre-approve the scooter. You say that you recommend the patient to have an electric 
scooter to assist with their activities of daily living. The Plan denied your request. The Plan says there is no 
evidence that a power operated vehicle is medically necessary. 
 
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 the scooter. Our reviewer says that the 
power mobility device (K0800) is not medically necessary. Our physician reviewer found the patient is 
functionally non-ambulatory and cannot perform their daily activities with the use of a cane or walker given 
their limited lower extremity range of motion and pain. However, they are noted to have nearly full strength in 
the upper extremities and can propel a manual wheelchair for mobility and performing their daily activities. 
Our reviewer also found that the patient was evaluated by physical therapy and a power mobility device was 
not needed to perform their daily activities and for mobility 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 the scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (scooter) (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parental drugs (D9612) provided on May 22, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you called the Plan prior to the date of service to 
confirm that the anesthesia would be covered. The Plan denied your request. The Plan says the denial of 
payment for this service is correct because the therapeutic parental drugs are not covered by the Plan. Also, it 
was verified that the call was regarding extractions and sedation, and you were told the correct benefits. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
therapeutic parental drugs (D9612) provided on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 18, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 21, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 80307 and G0481 for date of service September 6, 
2022. 
 
You asked the Plan to pay for codes 80307 and G0481. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
We find that CPT codes 80307 and G0481 are not supported in the medical record. Specifically, the 
documentation does not include drug test(s), presumptive, any number of drug classes, any number of devices 
or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, 
IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without 
chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed for the billed date of service; therefore, code 80307 is not 
supported. 
 
The documentation does not include rug test(s), definitive, utilizing (1) drug identification methods able to 
identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), 
including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and 
excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), 
(2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including 
metabolite(s) if performed for the billed date of service; therefore, code G0481 is not supported. 
 
Based on this information, we decided that Medicare rules for coverage of codes 80307 and G0481 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 80307 and G0481 for date of 
service September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical access to implant body (D6011) for tooth 
#19, #21, #28, and #30. 
  
You asked the Plan to pre-approve the dental services. You say that you need to have implants because you 
have a bridge in the upper part of your mouth. The Plan denied your request. The Plan says the denial of 
authorization for the surgical access to implant body is correct, because it cannot be applied until 3 months 
after the surgical placement of implant body. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the services requested are medically necessary following first stage implant placement, but the Plan's 
coverage criteria was not met. Our physician reviewer found that the implant second stage surgery is necessary 
to gain access to the implant to allow for final restoration. The question appears to be that the second stage 
procedure must be at least 3 months following the first stage surgical placement. As the submitted claim form 
was for pre-determination of benefits, there were no dates of service provided. This appears to be an 
administrative issue as to how to pre-determine benefits at the same time of procedures that follow others. The 
procedure itself would be necessary, however the pre-determination process at the administrative level needs to 
clarify coverage for the member as it is obvious that the second set of procedures would need to follow the first 
set by several months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the surgical access to implant body (D6011) for tooth #19, #21, #28, and #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99153 and G0269 billed for date of service 
March 13, 2023. 
 
You asked the Plan to pay for procedure codes 99153 and G0269. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says procedure code G0269 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 99153 has a PC/TC indicator of 3 on the Physician Fee Schedule. This means that 
procedure code 99153 is a technical component only code and should not be billed as a professional service. 
There may be an associated code to reflect the professional component of this service. We find that procedure 
code G0269 has a status indicator of B on the Physician Fee Schedule. This means that procedure code G0269 
is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure 
code G0269 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
99153 and G0269 billed for date of service March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 30, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 30, 2023.