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

 
We decided that the Plan does not have to pay for the mobile imaging services billed for date of service March 
1, 2022. 
 
You asked the Plan to pay for the billed services. You say that all services should be covered under the plan. 
The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim at issue was billed with 21, an inpatient hospital facility place of 
service code. There is a more accurate code that describes the location where the services were provided. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the mobile imaging services billed for date of 
service March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99203) 
rendered on February 6, 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 Current Procedural Terminology (CPT) code 99203-25 remains 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 99203 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 30-44 minutes of 
total time is spent on the date of the encounter." 
 
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 documentation does not 
support CPT 99203 with the -25 modifier, as there was no procedure performed alongside the office visit. The 
physician counseled the enrollee on different treatments, and only ordered an electromyography. However, no 
procedure was performed. 
 
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 evaluation and management services (procedure code 99203) rendered on February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 3, 2023, and billed with codes 87556 and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on April 3, 2023, and billed with codes 87556 and 87481.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary.  The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81433) provided on May 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes 
a single procedural service, so one procedure code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Code 
81432 was approved for this service. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(81433) provided on May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because the records show the enrollee 
had a radiofrequency ablation procedure of these same levels and side less than 5 months ago. 
 The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients that meet specific criteria. 
 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not medically necessary. Our physician reviewer found the records 
show that the enrollee had a radiofrequency ablation procedure of the same levels and side, less than 5 months 
ago. The pain persists and thus, it is not reasonable to expect that the enrollee does not have non-facet 
pathology causing the persistent pain. The review has determined that the enrollee does not meet all of the 
coverage criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494).
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 6, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that payment is requested. 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. Therefore, we decided that the Plan does not have to pay for procedure code 81456 
billed for date of service February 6, 2023.
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 January 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests should not be 
included in the dialysis rate. 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 January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a K3 microprocessor knee and K3 foot (L5856 + L5828 + L5848 
+ L5845 + L5981).  
 
You asked the Plan to pre-approve a K3 microprocessor knee and K3 foot. You say that the items are medically 
necessary. The Plan denied your request. The Plan says that the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the Plan must cover item Original Medicare would 
cover. 
 
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 K3 microprocessor knee and K3 foot. 
Our reviewer says that the items are medically necessary. Our physician reviewer found lesser devices simply 
do not meet the enrollee's functional needs and would amount to substandard 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 a K3 microprocessor knee and K3 foot have been met. Therefore, we decided 
that the Plan has to pre-approve a K3 microprocessor knee and K3 foot (L5856 + L5828 + L5848 + L5845 + 
L5981).   
 
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 pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says IGRT is experimental/investigational for the enrollee's condition. 
 
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 IGRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that reducing cardiac exposure is not expected to have a clinically meaningful benefit in the enrollee who 
has widespread disease, for which prognosis is limited, using palliative doses which the heart would tolerate 
well and for which the heart exposure would be well within accepted constraints even with the use of more 
standard planning target volume (PTV) margins. The metastasis, based on the screen capture of the image, does not directly abut the heart and is more rightward positioned such that heart exposure is unlikely to be 
problematic with standard PTV margins. IGRT is not an accepted standard of care for routine use in the 
palliative treatment of bone metastases. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0955, 
E0978, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the power wheelchair and 
accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested power wheelchair and accessories. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee had no need for a ventilator or for power tilt and recline. 
The documentation does not support that the enrollee is at high risk for development of a pressure ulcer, 
utilizes intermittent catheterization for bladder management, or needs a power seating system to manage 
increased tone or spasticity. The enrollee has no history of prior pressure ulcer with prior wheelchair use and no 
documentation of flap surgery. The physician documentation does not reveal a detailed neuromuscular exam of 
the upper extremities indicating abnormal left upper extremity strength. There is no detailed extremity range of 
motion testing. The request for power and tilt exceeds the enrollee's medical needs. The base wheelchair was 
not approved therefore the accessories are not medically necessary. Also, the documentation also does not 
support that the enrollee does not have the strength in the left upper extremity to control any power options 
through their own switches. 
 
 
 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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0955, E0978, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99204) provided on April 26, 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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter". 
 
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 99204 is not supported by the records provided. Our reviewer found that the documentation did not describe a moderate 
level of decision making or the total time of the encounter being 45-59 minutes in duration. 
 
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 (99204) provided on April 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on November 12, 2022. 
 
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 complexity, history, physical, and consultation do not meet the code criteria. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate 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 presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function." 
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 documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of moderate complexity. 
The records do not support the presenting problems were of high severity, posing an immediate threat to life 
and function. 
 
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 emergency room services (procedure code 99284) rendered on November 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous imaged-guided lumbar decompression 
(PILD) procedure (0275T). 
 
You asked the Plan to pre-approve a PILD procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the records show the 
enrollee does not have spinal stenosis at the index level. 
 
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 PILD procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging provided does not corroborate any spinal stenosis at 
the L4-5 level. There is no compelling rationale presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 PILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous imaged-guided lumbar decompression (PILD) procedure (0275T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical studies haven't proven that the requested service is helpful for the 
treatment of the enrollee's condition. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (52224, 52214, 74420) provided on May 17, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 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 codes 52224, 
52214, and 74420, is not supported by the records provided. Our reviewer found that for code 52224, the 
record does not mention fulguration or treatment, just random biopsies of the bladder. There is a more 
appropriate way to report this procedure. For code 52214, the record does not mention treatment of a lesion by 
fulguration of the trigone, bladder neck, prostatic fossa, urethra, or periurethral glands. The record mentions resection of part of the urethra for a biopsy. There is a more appropriate way to report this procedure. For code 
74420, the documentation does not contain evidence that a retrograde urography was performed during this 
encounter. 
 
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 (52224, 52214, 74420) provided on May 17, 2023.