Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services described by codes 14301 and 14302 
performed on July 18, 2023. 
 
You asked the Plan to pay for 14301 and 14302. You say that 14301 and 14302 should be paid as billed 
because modifier -82 was appended, and these services were medically necessary. The Plan denied your 
request. The Plan says 14301 and 14302 are denied because modifier -82 was appended, but the assistant-at-
surgery services were provided by a physican assistant rather than a physican. 
 
The Plan must follow Medicare rules. Medicare rules say that modifiers -80, -81, and -82 are used for assistant-
at-surgery services provided by physicians. The -AS modifier is used for assistant-at-surgery services 
performed by physician assistants, nurse practitioners, and clinical nurse specialists. 
 
We looked at the file and Medicare rules. In this case, we confirmed that modifier -82 was appended to codes 
14301 and 14302. We confirmed that modifier -AS was not appended. Per Medicare rules, modifier -82 
indicates that the assistant-at-surgery services were provided by a physican, and -AS is for use when the assistant-at-surgery is a physican assistant, nurse practitioner, or clinical nurse specialist. Both the claim and 
the medical records in this case show that the provider performing assistant-at-surgery services is a physican 
assistant. As such, modifier -82 is not appropriate. Based on this information, we decided that Medicare rules 
for coverage of 14301 and 14302 have not been met. Therefore, we decided that the Plan does not have to pay 
for the surgical services described by codes 14301 and 14302 performed on July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic arm (E1399). 
 
You asked the Plan to pre-approve the robotic arm. You say that this feature is medically necessary The Plan 
denied your request. The Plan says this device is experimental and non-covered. 
 
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 robotic arm. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records provided do not support that this device is medically necessary for the enrollee's condition. 
 
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 robotic arm have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a robotic arm (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 13, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on August 
28, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this service was fully 
covered in the past. 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 $40 
copayment for outpatient hospital services. 
 
You have been asked to pay a $40 copayment for the laboratory services. This item/service falls within the 
outpatient hospital services 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 the 
laboratory services provided on August 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93005 billed for date of service August 23, 
2023. 
 
You asked the Plan to pay for procedure code 93005. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 find that CPT code 93005 is not supported. Specifically, a review of the status indicators and definitions of 
these codes shows that code 93005 has an indicator of Q1, stating that payment is packaged with services 
showing a status indicator of S, T, or V. As an emergency-care code, code 99285 has a status indicator of V. 
Therefore, separate payment for code 93005 is not appropriate. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93005 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93005 billed for date of service August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
January 20, 2023, through February 9, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
have submitted medical records for review. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show this device is being requested to improve circulation after 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on January 20, 2023, through February 9, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 14 skilled nursing home visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the home health services. You say that you would like to remain with the 
same provider and to have the requested services covered. The Plan denied your request. The Plan says that the 
denial of authorization for these services is correct, because the provider is an OON provider. 
 
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. We find that The Plan has not substantiated their denial reason for the home 
health services because the provider being an OON provider. The enrollee is on a PPO Plan and the enrollee is 
eligible to see in-network providers and OON providers. Therefore, we decided that the Plan has to pre-
approve 14 skilled nursing home visits to be provided by an out-of-network (OON) provider.  
 
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 the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that 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 
patient's brachial plexus condition or in widespread use for this patient'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 patient. 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig.  
 
You asked the Plan to pre-approve a wig. You say that the enrollee suffers from alopecia totalis. The total loss 
of her hair is affecting her emotional well-being and quality of life. The Plan denied your request. The Plan 
says wigs are not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc NP procedure. 
 
You asked the Plan to pre-approve the VIA Disc NP procedure. You say that the enrollee requires the requested 
procedure to minimize their pain levels. The Plan denied your request. The Plan says the requested procedure 
does not meet the criteria 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 pre-approve the VIA Disc NP procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested injection of allograft (in this case, VIA Disc NP) into the 
intervertebral disc for the treatment of degenerative disc disease is considered investigational and not medically 
necessary for the treatment of degenerative disc disease. 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 VIA Disc NP procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the VIA Disc NP procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home modifications to allow for a walk-in shower. 
 
You asked the Plan to pre-approve a walk-in shower. You say that you can't put your legs up over your tub, and 
it is very hard to get into and out of the shower. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
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. 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 home modifications to allow for a walk-in shower.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 31, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this claim was coded appropriately. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R09.02 has an Excludes1 note in relation to J80. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance services provided on March 31, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97010 and 97014 billed for date of service 
June 14, 2023. 
 You asked the Plan to pay for procedure codes 97010 and 97014. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says procedure code 97010 is considered bundled and 
not separately payable. Procedure code 97014 is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. 
 
We find that procedure code 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 97014 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 97010 and 97014 billed for date of service June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement to you for a lift chair (E1399) 
purchased April 26, 2023. 
 
You asked the Plan to provide additional reimbursement to you for a lift chair. You say that you were told you 
would be reimbursed 80% of the cost of medical equipment. 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay $85.50 ($341.98 x 20%) for a lift chair. This item/service falls within the Durable 
medical equipment (DME) and related supplies 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 provide 
additional reimbursement to you for a lift chair (E1399) purchased April 26, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from March 14, 2023, to March 23, 
2023. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that the DRG change was appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were supported by the medical records. Our physician reviewer found that 
the enrollee meets criteria for septic shock with proven E. coli. Therefore, diagnosis code A41.9 is justified. 
The documentation more supports DRG 871 than 683. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services rendered from March 14, 2023, to March 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 35221, 38747, 49905 rendered on July 14, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 35221: 
 
Repair blood vessel, direct; intra-abdominal  
CPT 38747: 
 
Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-
aortic and vena caval nodes (List separately in addition to code for primary procedure) 
 
CPT 49905: 
 
Omental flap, intra-abdominal (List separately in addition to code for primary procedure) 
 
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 CPT 35221 and 38747 are not 
supported as separately reportable procedures. The record shows that they are part of the main procedure 
reported with 48150 and should not be reported separately. Additionally, CPT 49905 is not supported. The 
record does not contain a description of an omental flap that was used for abdominal reconstruction. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 35221, 38747, 49905 rendered on July 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on July 29, 
2023, to August 01, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that this is an out-of-network 
provider and you didnt want to go to this hospital to begin with. 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 $315 
copayment for inpatient hospital care.  
You have been asked to pay a $315 copayment for an acute inpatient stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay a total of $945 for the inpatient hospital stay ($315 copayment 
x 3 days = $945). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for an acute inpatient stay provided on July 29, 2023, to August 01, 
2023.