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

 
We decided that the Plan does not have to pre-approve an adjustable volume socket for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve an adjustable volume socket. You say that an adjustable volume socket is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says an adjustable volume socket is 
experimental/investigational. 
 
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 adjustable volume socket. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has undergone a left-sided transfemoral amputation and requires a 
transfemoral prosthesis for mobility and accomplishing daily activities. However, there is a lack of information 
establishing whether the requested adjustable volume socket is medically appropriate given the enrollees 
clinical history and medical condition. The enrollee has had bilateral lower extremity amputation due to 
peripheral vascular disuse, but there is no indication of significant volume fluctuation in the lower extremities 
that would necessitate the adjustable volume socket. 
 
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 adjustable volume socket have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an adjustable volume socket for a lower-limb prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on February 
2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit.    Therefore, we decided that the Plan does not have to pay for the 
inhalation of nitrous oxide (D9230) provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 25 additional units of procedure code 15111 billed for date of 
service October 3, 2022. 
 
You asked the Plan to pay for 25 additional units of procedure code 15111. You say that the services at issue 
have been billed correctly. The Plan denied your request. The Plan says the provided records do not support the 
services as 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 25 additional units of procedure code 15111. Our reviewer 
says that 25 additional units of procedure code 15111 do not meet criteria for payment. Our reviewer found that 
the record does not support an additional 25 units of 15111. The record states that 1100 square centimeters of 
the epidermal autograft was performed, which equals the initial unit plus 10 additional 100 square centimeter 
units as approved by the Plan. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 25 additional units of procedure code 15111 have not been met. Therefore, we 
decided that the Plan does not have to pay for 25 additional units of procedure code 15111 billed for date of 
service October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87899 and 87900) provided on 
October 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that these lab services were medically 
necessary.  The Plan denied your request. The Plan says codes 87899 and 87900 are not supported by the 
medical record. 
 
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 87899 is infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; not otherwise specified. The definition of code 87900 
infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 laboratory services. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
documentation to verify infectious agent antigen detection by immunoassay with direct optical observation has 
been performed. Our coder was unable to cite report, as this procedure was not found in documentation. For 
Current Procedural Terminology (CPT) 87899: The lab analyst performs the technical lab test to analyze for an 
infectious agent by immunoassay with direct optical, meaning visual, observation. This procedure was not 
found in medical record. 
 
For code 87900, the documentation submitted was reviewed and does not meet criteria. The laboratory report 
does not include documentation of infectious agent drug susceptibility phenotype prediction using regularly 
updated genotypic bioinformatics. Our coder was unable to cite report, as this procedure was not found in 
laboratory report. For 87900: The lab analyst measures a patient's susceptibility or resistance to drugs aimed at 
a virus. The test predicts the behavior of the phenotype based on comparing patient data to regularly updated 
genotypic bioinformatics. The clinician can use the information to help in deciding which drugs to prescribe. 
This procedure was not found in medical record. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87899 and 87900) provided on October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freedom Quattro microprocessor knee (L5856, L5828, 
L5848, L5845, L5850, L5925).  
 
You asked the Plan to pre-approve the knee. You say that your functional level has increase from a K2 to a K4. 
You also say that the requested components are appropriate for your level of activity.  The Plan denied your 
request. The Plan says the requested microprocessor knee exceeds your medical need.  
 
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 knee. Our physician reviewer found 
Freedom Quattro microprocessor knee (L5856, L5828, L5848, L5845, L5850, L5925) exceeds the patient's 
needs per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), as Medicare does not 
pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or 
injury or to improve the functioning of a malformed body member. An online review of this product reveals 
that this knee has a cycling and golf mode which appear to exceed your functional needs. Additionally, the 
physician documentation does not reveal why a mechanical knee is unable to meet your functional needs.  
 
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 knee have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freedom Quattro microprocessor knee (L5856, L5828, L5848, L5845, L5850, L5925).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 95822-XU billed for date of service March 8, 2022. 
 
You asked the Plan to pay for code 95822-XU. You say that you have supplied proper proof and 
documentation to support payment. The Plan denied your request. The Plan says code 95822-XU is not 
supported by the medical records. The records do not indicate that electroencephalogram (EEG), recording in 
coma or sleep only was performed. There is a more appropriate code that should have been 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. 
 
In this case, the CPT Code Manual definition of code 95822-XU is Electroencephalogram (EEG); recording in 
coma or sleep only. 
 
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 95822-XU. Our reviewer says that code 95822-XU is 
not supported in the medical record. Our reviewer found the procedure report documents neuromonitoring 
services provided for, a decompression L4-S1 posterolateral fusion procedure.  In this case, this is an 
inappropriate code to report for service provided.  There is a more appropriate code to report for service 
provided. 
 
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 95822-XU have not been met. Therefore, we decided that the Plan does 
not have to pay for code 95822-XU billed for date of service March 8, 2022.
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 the DME. You say that the expandable controller and harness are necessary 
for the safe operation of the power wheelchair due to your traumatic brain injury.  The Plan denied your 
request. The Plan says  an electronic connection (E2311), harness (E2313), and expandable controller (E2377) 
cannot be covered as it is not medically necessary to control the three approved 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 the DME. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that it is medically necessary to control the requested 
power options through the joystick (drive interface). Your upper extremity strength and functional ability as 
evidenced by being independent for feeding should be sufficient to control any power options through their 
own switches. The documentation does not reveal that the E2377 Expandable Controller, E2313 Expandable 
Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are medically necessary 
as the requested items exceed your needs per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
Section 411.15(k). 
 
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 DME 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup provided on January 12, 2023 
 
You asked the Plan to pay for the dental service. You say that you were advised that the provider is in-network 
with the Plan. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup provided on January 12, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99215 billed for date of service July 26, 2022. 
 
You asked the Plan to pay for code 99215. You say that these services were provided in good faith and should 
be paid in full. The Plan denied your request. The Plan says code 99215 is not supported by the medical 
records. The records don't support medical decision making of high complexity. 
 
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 99215 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least two of these three key components: a 
comprehensive history; a comprehensive examination; medical decision making of high complexity. 
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to 
high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 
 
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 99215. Our reviewer says that code 99215 is not 
supported by the medical record. Our reviewer found the enrollee was a 78 year old female with a history of 
diabetes, hypertension, hyperlipidemia, deep vein thrombosis, pulmonary embolism, and Sjogren's  syndrome 
who was evaluated for and echocardiogram and electrocardiograph follow-up exam. There was no 
documentation of medical decision making of high complexity. 
 
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 99215 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99215 billed for date of service July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 24, 2022, billed with 
codes 81272, 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
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 
October 24, 2022, billed with codes 81272, 81314 and 81345.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 18, 2022, billed 
with codes 81227, 81231, 81232, 81238, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
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 
November 18, 2022, billed with codes 81227, 81231, 81232, 81238, 81291, 81306, 81328, 81335 and 81479.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on May 23, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you feel the cost share is too high. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $150 copayment for a CT scan. This item/service falls within the outpatient 
diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on 
May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service January 19, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that the records support medical necessity of 
these services. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment 
for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service January 19, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001) and elevating legrests 
(K0195). 
 
You asked the Plan to pre-approve a manual wheelchair (K0001) and elevating legrests (K0195). You say that 
the requested manual wheelchair (K0001) and elevating legrests (K0195) are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for a manual wheelchair (K0001) or 
elevating legrests (K0195). 
 
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 manual wheelchair (K0001) and 
elevating legrests (K0195). Our reviewer says that the enrollee does not meet criteria for a manual wheelchair 
(K0001) or elevating legrests (K0195). Our physician reviewer found the enrollee suffered a fall and continues 
to experience knee pain. She is noted to have a knee effusion. However, there is no clinical documentation 
indicating the enrollees level of mobility and function. There are also no physical examination findings 
regarding the enrollees range of motion and motor strength for the lower extremities. There is no indication 
that the enrollee cannot complete her mobility related daily activities of living with a cane or walker. There is 
no indication that the enrollee can use the requested manual wheelchair and has the capacity to propel it. 
Therefore, the manual wheelchair (K0001) and elevating leg rests (K0195) are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a manual wheelchair (K0001) and elevating legrests (K0195) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0001) and 
elevating legrests (K0195).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for September 30, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99153 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone codes.  

We looked at the file and Medicare rules. Procedure code 99153 has a PC/TC indicator of 3 and no separate PC 
payment. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
September 30, 2022.