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

 
We decided that the Plan does not have to pay for code G0378 billed for date of service November 23, 2022. 
 
You asked the Plan to pay for code G0378. You say that this service was medically necessary and rendered in 
good faith. The Plan denied your request. The Plan says no separate payment is made for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that codes billed under the Outpatient Prospective 
System (OPPS) that have the status indicator of N on Addendum B- OPPS Payment by HCPCS Code for 
Calendar Year 2022 are not paid separately.  Payment for these services is packaged into payment for other 
services. 
 
 In this case, the code in dispute (G0378) has a status indicator of N.  This means that no separate payment is 
made for this code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code G0378 have not been met. Therefore, we decided that the Plan does not have to pay for code 
G0378 billed for date of service November 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring (IONM) testing 
rendered on August 23, 2022. 
 
You asked the Plan to pay for the services. You say that you have submitted supporting documentation for 
reconsideration. The Plan denied your request. The Plan says intraoperative neurophysiology testing is not a 
Medicare benefit for the diagnoses listed on the claim or during the procedure documented in the record. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee underwent radiofrequency ablation (RFA) of their thoracolumbar spine. 
This is not a procedure for which the applicable LCD supports the use of neuromonitoring services. The use of 
IONM in RFA is not otherwise readily supported within current literature. In as much this request would not be 
medically necessary/eligible for coverage. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for intraoperative neurophysiology monitoring (IONM) testing rendered on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with 
AVAPS and a back-up rate. The enrollee's average use of the device (when she uses it, is 2.0 hours per day). 
Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the alignable system. We decided that the Plan does not have to 
pre-approve the multi-axial rotational unit. 
 
You asked the Plan to pre-approve an alignable system described by code L5920 and a multi-axial rotational 
unit described by code L5986 for a lower limb prosthesis. You say that you disagree with the denial. The Plan 
says that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve the alignable system. 
 
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 these services. Our reviewer says that 
the alignable system is medically necessary. Our physician reviewer found that the medical records are 
sufficient to support that a replacement socket is medically necessary. The requested alignable system is not 
usually recycled between sockets because it is laminated directly into the structure of the previous socket. The 
documentation supports that the alignable system is reasonable and medically necessary 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 the alignable system have been met. Therefore, we decided that the Plan has to 
pre-approve the alignable system described by code L5920. 
 
We also decided that the Plan does not have to pre-approve the multi-axial rotational unit. 
 
The Plan must follow Medicare rules. The rules say that a multi-axial rotational unit is covered when medically 
necessary.  
 
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 these services. Our reviewer says that 
the multi-axial rotational unit is not medically necessary. Our physician reviewer found that the requested 
multi-axial rotation unit requested under code L5986 does not describe an entire foot. The services cannot be 
approved with this code. 
 
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 multi-axial rotational unit 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.  
Therefore, we decided that the Plan does not have to pre-approve the multi-axial rotational unit described by 
code L5986. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test genetic panel (0312U) provided 
September 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please see the attached documents and scientific 
evidence supporting the effectiveness of AVISE testing. The Plan denied your request. The Plan says the AVISE CTD test panel is considered experimental and investigational as it i unproven to alter disease 
prognosis or treatment outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the AVISE CTD test genetic panel (0312U) provided September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test genetic panel (0321U) provided 
September 15, 2022. 
 
You asked the Plan to pay for genetic testing. You say that please see the attached documents and scientific 
evidence supporting the effectiveness of AVISE testing. The Plan denied your request. The Plan says AVISE CTD test panel is considered experimental and investigational as it is unproven to alter disease prognosis or 
treatment outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at and Medicare rules. Per the DEX Diagnostic Exchange Registry, this testing is considered not 
covered after the Molecular Diagnostics (MoIDx) program evaluation. Based on this information, we decided 
that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the AVISE CTD test genetic panel (0321U) provided September 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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. While the medical record supports a need for physical 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 this 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test genetic panel (0321U) provided June 
30, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please see the attached documents and scientific 
evidence supporting the effectiveness of AVISE testing. The Plan denied your request. The Plan says AVISE CTD test panel is considered experimental and investigational as it is unproven to alter disease prognosis or 
treatment outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Per the DEX Diagnostic Exchange Registry, this testing is 
considered not covered after the molecular diagnostic (MoIDx) program evaluation. Based on this information, 
we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the AVISE CTD test genetic panel (0321U) provided June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 provided on January 14, 2023. 
 
You asked the Plan to pay for procedure code 93042. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the record does not support the billing of code 
93042. 
 
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 93042 is Rhythm ECG, 1-3 leads; interpretation and 
report only. 
 
We find that CPT code 93042 is not supported in the medical record. Specifically, there is no record showing 
that this service was performed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 93042 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 93042 provided on January 14, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for removal of impacted cerumen using irrigation/lavage (69209) provided 
on February 8, 2023. 
 
You asked the Plan to pay for ear wax removal. You say that this was an urgent care visit and should not 
require a referral. The Plan denied your request. The Plan says that this code was not billed with a required 
anatomic modifier. 
 
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 did not submit any medical records for review, nor any attempts to 
obtain medical records. Without records, we cannot determine whether the code is payable as it has been billed 
on this claim. Therefore, the Plan has not shown that its decision to deny payment for this service is correct or 
justified according to Medicare billing guidelines. Therefore, we decided that the Plan has to pay for removal 
of impacted cerumen using irrigation/lavage (69209) provided on February 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 24, 2023. 
 
You asked the Plan to pay for the dental service (D7953). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81292) provided on May 30, 2022. You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81292) provided on May 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the requested inpatient 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,  
 consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. 
Our physician reviewer found that the provided documentation did not describe the enrollee as having an 
unstable condition or high risks that would expect a prolonged recovery or high risk of complication for this 
typically ambulatory procedure to require hospital services that would be expected to cross two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81314, 81345, and 81272) provided on 
December 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81314, 81345, and 81272) provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (PVA) (22514). 
 
You asked the Plan to pre-approve a PVA. You say that the enrollee is in a tremendous amount of pain. You 
also say that the enrollee needs this procedure done. The Plan denied your request. The Plan says the requested 
service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures may be considered medically reasonable and 
necessary for painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that 
have not responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g. rest, bracing). 
 
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 PVA. Our reviewer says that the 
requested PVA is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate the enrollee has trialed fracture bracing. The reviewer found that additional conservative measures are 
needed. Therefore, the reviewer found that the requested PVA is not medically reasonable or necessary 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 PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a percutaneous vertebral augmentation (PVA) (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, and 87641 billed for 
date of service November 11, 2022. 
 
You asked the Plan to pay for procedures code 87150, 87481, 87653, and 8764. You say that you disagree with 
the denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, 87653, and 8764 is 
bundled into payment for code 87500. 
 
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 codes 
87150, 87481, 87653, and 8764 are column II codes to column I code 87500. This claim has not been billed 
with an appropriate modifier to bypass the edit. The -XU modifier is not supported for these codes as separate 
and distinct procedures. 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 codes 87150, 87481, 87653, and 87641 billed for 
date of service November 11, 2022.