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

 
We decided that the Plan does not have to pay for the lab testing provided on March 16, 2023, billed with code 
83520. 
 
You asked the Plan to pay for the lab testing as billed. You say that this code is valid and should be paid. The 
Plan denied your request. The Plan says there is no description given for this unlisted code.  
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, the claim was not billed with 
information to identify the type of immunoassay reported under this not otherwise specified code. Based on this information, we decided that Medicare rules for coverage of the lab testing as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing provided on March 16, 2023, billed 
with code 83520.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77427 rendered on March 22, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider billed with only one fraction/date of service. 
 
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 77427 is "Radiation treatment management, 5 
treatments. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided documentation only 
includes the end of treatment summary plan. The available documentation does not fully support CPT 77427 for March 22, 2023. CPT 77427 was not reported correctly in this case. 
 
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 procedure code 77427 rendered on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, A9901, E0955, 
E0956, E0960, E1007, E1028, E2209, E2300, E2323, E2359, E2615, E2622, and K0108). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power options and 
additional items and accessories. The Plan denied your request. The Plan says the enrollee does not have 
medical need for multiple power options included with K0861 group 3 power wheelchair. The Plan also says 
the 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 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
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 a Group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found the enrollee has normal strength in their upper 
extremities and intact skin. The enrollee is continent and does not require assistance toileting. Our reviewer 
found that the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity 
or require an alternative means of managing power drive. 
 
 
 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 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E2311, E2313, E2377, A9901, E0955, E0956, E0960, E1007, E1028, E2209, E2300, 
E2323, E2359, E2615, E2622, and K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care, per day, 
for the evaluation and management of a patient (99233) provided on April 25, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. You say that you request 
reconsideration and have submitted medical records for review. The Plan denied your request. The Plan says 
code 99233 remains not supported. The medical records submitted do not support high level of medical 
decision making or total time required of the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 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 subsequent hospital inpatient or observation care. Our 
reviewer says that the service does not meet criteria for approval of payment on this claim. Our reviewer found 
the provider reported CPT 99233, which requires at least 2 of these 3 key components: detailed history; 
detailed examination; and medical decision of high complexity for service provided. The documentation 
submitted was reviewed and does not meet criteria. In this case, there is a more appropriate code that would be 
reported for supporting documentation, CPT 99232. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital inpatient or observation care have not been met. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital inpatient or observation care, per day, for 
the evaluation and management of a patient (99233) provided on April 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominal paracentesis with imaging guidance 
(49083) to be rendered by an out-of-network (OON) provider. 
 You asked the Plan to pre-approve an abdominal paracentesis with imaging guidance. You say that the patient 
needs a procedure and if they do not have it, it will affect their health. The Plan denied your request. The Plan 
says medically necessary care is available in-network. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from the enrollees home who can provide an abdominal 
paracentesis with imaging guidance. Under Medicare rules, this means that contract providers are accessible to 
the enrollee. Therefore, we decided that the Plan does not have to pre-approve an abdominal paracentesis with 
imaging guidance (49083) to be rendered by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87581, 87798, U0005) provided on October 
28, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says a lab order was not 
submitted. 
 
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 U0005 
is an add-on code and has not been billed with an appropriate payable primary procedure code. Additionally, 
the documentation submitted does not contain a valid physician order or lab requisition for the billed lab 
services (87581, 87798). The documentation submitted does not contain medical records showing the ordering 
physicians intent that this testing be performed. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab services (87581, 87798, 
U0005) provided on October 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a parathyroid scan. 
 
You asked the Plan to pre-approve a parathyroid scan. You say that the records provided support the need for 
the requested radiology services. The Plan denied your request. The Plan says the medical records provided do 
not show that the enrollee has parathyroid and calcium levels which are elevated or that surgery is planned. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a parathyroid scan. Our reviewer says 
that a parathyroid scan is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has undergone bariatric surgery.  The record provided is 
insufficient to support the medical necessity of the requested service at this time. 
 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 parathyroid scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a parathyroid scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 20, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. You say the enrollee's performance status is very poor due to their multiple medical 
problems. The Plan denied your request. The Plan says your request for approval of admission to a SNF does 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist; 
however, the enrollee does not require skilled therapy services on a daily basis. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections.  
 You asked the Plan to pre-approve the injections. You say that the facet joint injections are medically necessary 
to treat the enrollee's pain related to lumbar spondylosis. The Plan denied your request. The Plan says that facet 
joint injections are 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 the injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that the utility of intra-articular 
facet joint injections is controversial and not recommended by clinical practice guidelines as a pathway to 
radiofrequency ablation of the medial branch nerves. Also, the enrollee has other probable pain generators and 
therefore the request does not meet the LCD criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve injections. 
 
You asked the Plan to pre-approve the injections. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Hayek biphasic cuirass ventilator (E1399). 
 
You asked the Plan to pre-approve the Hayek biphasic cuirass ventilator. You say that the enrollee has a 
complex history with significant neuromuscular changes seen with cerebral palsy. The device is medically 
necessary. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show the enrollee has been doing well with a positive airway pressure (PAP) therapy device in the 
treatment of obstructive sleep apnea. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 Hayek biphasic cuirass ventilator. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
evidence of medical necessity or need for this device provided. The enrollee does not meet the requirements for 
the device. 
 
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 Hayek biphasic cuirass ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Hayek biphasic cuirass ventilator (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
requesting reconsideration due to medical necessity. The Plan denied your request. The Plan says the records 
do not show at least four-week trial of daily, multiple-hour home usage of the basic pump. The enrollee does 
not meet criteria for approval of the device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an iovera procedure. 
 
You asked the Plan to pre-approve the cryoablation. You say that this procedure is necessary for functional 
improvement and pain management. The Plan denied your request. The Plan says the request 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 the nerve destruction. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that cryoablation/cryoneurolysis of peripheral nerves to treat pain is 
experimental/investigational. It has not been scientifically demonstrated to improve patient clinical outcomes. 
There is not enough medical evidence that shows the procedure is helpful.  
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 nerve destruction have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an iovera procedure.