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

 
We decided that the Plan does not have to pre-approve a knee orthosis. 
 
You asked the Plan to pre-approve a knee orthosis. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthoses are 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 a knee orthosis. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not reveal an 
objective description on a physical examination of joint laxity/instability. The enrollee is ambulatory, but the 
documentation does not reveal a knee contracture, recent knee surgery or injury. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on October 11, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange.  
 
We looked at the file and Medicare rules. The billed testing is not covered under the DEX Diagnostics 
Exchange. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the testing provided on October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided 
November 29, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the treating physician, determined that 
ordering the F1CDx test is medically necessary for the enrollee to assist in treatment decisions. The Plan 
denied your request. The Plan says based on Medicare guidelines, the genetic testing, FoundationOne CDx 
testing (0037U) does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per the NCCN Guidelines tumor/somatic molecular profiling is recommended for 
patients with locally advanced/metastatic pancreatic cancer who are candidates for anticancer therapy to 
identify uncommon mutations. This enrollee is reported to have early-stage disease and would not meet criteria 
for testing. The service is not reasonable or 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the FoundationOne CDx testing (0037U) provided November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on December 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that the eyeglasses should be reimbursed. The Plan 
denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one pair of conventional eyeglasses 
or contact lenses furnished after each cataract surgery with insertion of an IOL.  
 
The services show that progressive lenses were provided. These are not covered by Medicare or your plan. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 provided on 
December 7, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. In addition, codes 94761 and 99072 are 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. The rules also say that for molecular 
diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine 
whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is 
assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87631 
have not been met. 
 
In addition, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. We have also confirmed that procedure code 94761 
has a status indicator of T on the Physician Fee Schedule and was billed with other payable services under the 
physician fee schedule for the same date by the same provider. This means that procedure code 94761 is not 
separately payable in this case. Based on this information, we decided that Medicare rules for coverage of 
codes 99072 and 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87631, 94761 and 99072 provided on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical stimulation device used for cancer treatment 
(E0766). 
 
You asked the Plan to pre-approve electrical stimulation device. You say that you have brain cancer. You also 
say that this device can potentially prolong your current life expectancy. The Plan denied your request. The 
Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that tumor treatment field therapy (TTFT) is covered for 
the treatment of newly diagnosed Glioblastoma Multiforme (GBM). 
 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 electrical stimulation device. Our 
reviewer says that the requested electrical stimulation device is not medically necessary. Our physician 
reviewer found the documentation does not support that the enrollee in this case has a histologically confirmed 
(World Health Organization (WHO) grade IV astrocytoma), newly diagnosed, supratentorial glioblastoma 
multiforme (GBM). Therefore, the reviewer found that the requested electrical stimulation device is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electrical stimulation device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve electrical stimulation device used for cancer treatment (E0766).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on January 23, 2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that the provider is certified to provide 
opioid treatment services. The Plan denied your request. The Plan says that the incorrect provider type billed 
for these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for opioid treatment 
services provided on January 23, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee has fallen multiple times from 
weakness. For the enrollee to be able to do daily activities, he will need a power wheelchair. The Plan denied 
your request. The Plan says the request is not medically necessary because the records show the enrollee does 
not have adequate strength and ability to transfer in and out of or to operate a power scooter. 
 
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.  
 The file shows that you cannot safely operate the power scooter being requested and you do not have adequate 
strength and ability to transfer in and out of a power scooter. This means 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 
operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel services coded as 81225 81226 81227 
81231 81238 81291 81306 81335 81355 81401 provided on June 10, 2022, by an out-of-network (OON) 
provider.  
You asked the Plan to pay for the laboratory services. You say that you have asked the provider to supply you 
with the medical records of the office visits to support the billing and request review and reconsideration for 
payment. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory panel services coded as 81225 
81226 81227 81231 81238 81291 81306 81335 81355 81401 provided on June 10, 2022, by an out-of-network 
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 21, 2022 to July 20, 
2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 21, 2022. The NOA was not received by the Plan until October 21, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on June 21, 2022 to July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95885, 95907, 95927, and 95955 billed on July 12, 
2021. 
 
You asked the Plan to pay for codes 95885, 95907, 95927, and 95955. You say that these services were billed 
correctly. The Plan denied your request. The Plan says these codes are not supported in the records. 
 
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 95885 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
limited (List separately in addition to code for primary procedure). The definition of 95907 is nerve conduction 
studies; 1-2 studies. The definition of 95927 is short-latency somatosensory evoked potential study, stimulation 
of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. The 
definition of 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).  
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 codes 95885, 95907, 95927, and 95955. Our reviewer says 
that the billed codes are not supported. Our reviewer found the record does not contain evidence that short-
latency somatosensory evoked potential studies of the trunk and head were performed to support 95927. The 
record also does not contain a professional interpretation of an electroencephalogram (EEG) performed during 
a non-intracranial procedure to support 95955. The record states that pedicle screws were placed and stimulated 
to monitor the level or responsiveness under anesthesia. This does not meet the requirements for reporting 
nerve conduction studies or the add-on code for needle electromyography as described by 95907 and 95885. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95885, 95907, 95927, and 95955 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 95885, 95907, 95927, and 95955 billed on July 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services billed for date of service January 23, 2023. 
 
You asked the Plan to pay for the opioid treatment services. You say that this provider is eligible to bill for 
opioid treatment services. The Plan denied your request. The Plan says that the wrong provider type billed for 
these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for opioid treatment 
services billed for date of service January 23, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Inpatient Evaluation and management (EM) services 
provided on September 17, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM services provided. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says the medical records submitted don't support a detailed 
interval history and 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 99223 is the Initial hospital care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our physician 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 EM services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the provided notes did not show evidence 
of comprehensive history or physical, nor was there evidence of medical decision-making of high complexity 
for the billed dates. 
 
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 EM services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for Inpatient Evaluation and management (EM) services provided on September 17, 
2022, billed with code 99223.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99217 billed for date of service June 8, 2022. 
 
You asked the Plan to pay for procedure code 99217. The Plan denied your request. The Plan says payment for 
code 99217 is bundled into payment for code 99236. 
 
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 99217 
is a column II code to column I code 99236 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 99217 billed for date of service June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve a powered upper extremity range of motion assist device. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria 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 a powered upper extremity range of 
motion assist device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the MyoPro Orthosis is not known to be 
effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this enrollee's condition or in widespread use for this 
enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the 
MyoPro Orthosis will improve the long-term outcomes for this enrollee. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 
 
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 powered upper extremity range of motion assist device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion 
assist device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing table (E0638). 
 
You asked the Plan to pre-approve standing table. You say that you are unable to walk and your doctor does 
not want you to fall before your surgery. The Plan denied your request. The Plan says this item is not covered 
by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare has explicitly categorized standing tables as convenience items that are not primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a standing table (E0638).