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

 
We decided that the Plan does not have to pay for the laboratory services billed with procedure codes 87640-
59, 87500, and 87798-59 for date of service September 27, 2022. 
 
You asked the Plan to pay for the laboratory services billed with procedure codes 87640-59, 87500, and 87798-
59. You say that you disagree with the denial. The Plan denied your request. The Plan says payment for code 
87640 is bundled into payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. The -59 modifier is not supported as a separate and distinct 
procedural service. Based on the claim submitted, Medicare billing criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of codes 87500 and 87798-59 are not met. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services billed with procedure codes 
87640-59, 87500, and 87798-59 for date of service September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313),
expandable controller (E2377) and attendant control (E2331) for the enrollee.

You asked the Plan to pre-approve an electronic connection, harness, expandable controller and attendant
control. You say that when three or more power seating functions/actuators/motors are provided, one unit of
E2311, one unit of E2377, and one unit of E2313 are allowed. You also say that the denial of the attendant
control does not make the base or any other accessories unusable. The Plan denied your request. The Plan says
that although there are three requested power options (tilt, recline and elevating leg rests), there is not a medical
need to control these power options through the joystick. The Plan also says that an attendant control cannot be
covered in addition to a beneficiary-operated joystick.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection, harness and expandable controller. Our Medical Director states that the patient has a medical
history of non-traumatic spinal cord injury due to neurosarcoidosis status post lesion resection in 2002 and/or
transverse myelitis. She requires a power mobility device for mobility. The enrollee is noted to have lower
extremity spasticity. A power mobility evaluation dated January 18, 2023, indicates that the enrollee has been
using a power scooter for mobility but is unsafe with transfers. The patient is non-ambulatory and requires
minimal assistance with transfers. It is documented that the upper extremity range of motion is within
functional limits with 4/5 strength. The documentation supports that the enrollee's upper extremity strength is
adequate to control the power options using their own switches. Our Medical Director found that the enrollee's
condition does not meet criteria for coverage of an electronic connection, harness and expandable controller.

We looked at this physician's review, the file, and Medicare rules. Medicare rules say that if an attendant
control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as noncovered.
A beneficiary-operated drive control is built into the base wheelchair that was approved. Based on this
information, we decided that Medicare rules for coverage of an electronic connection, harness, expandable
controller and attendant control have not been met. Therefore, we decided that the Plan does not have to preapprove
an electronic connection (E2311), harness (E2313), expandable controller (E2377) and attendant
control (E2331) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482) provided March 31, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that the billed diagnoses are appropriate, and you 
are appealing the claim for further processing. The Plan denied your request. The Plan says under Medicare 
rules, the number of definitive urine drug classes requested are not medically necessary. 
 
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 testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain being prescribed oxycodone/acetaminophen, 
methotrexate, Cosentyx, and gabapentin. Definitive urine drug testing (UDT) for 15-21 drug classes (G0482) 
was requested. However, the provided documentation didn't show recent unexpected urine drug screening 
results or documentation of signs or symptoms of likely drug abuse/misuse to warrant definitive drug testing, 
particularly for 15+ drug classes when only 3 drug classes were being prescribed. Therefore, this request for 
definitive drug testing will be considered not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided 
March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 10, 2023.

You asked the Plan to pay for OIVIT services. You say that the OIVIT services should paid as billed because they are supported in the documentation and were medically necessary. The Plan denied your request. The Plan says the OIVIT services are denied because they are not supported in the documentation.

The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921), oral hygiene instructions 
(D1330), and an adjunctive pre-diagnostic test (D0431) provided on August 16, 2023. 
 
You asked the Plan to pay for D4921, D1330, and D0431. You say that this dental work was all necessary. The 
Plan denied your request. The Plan says these services have been processed correctly. 
 
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 gingival 
irrigation (D4921), oral hygiene instructions (D1330), and an adjunctive pre-diagnostic test (D0431) provided 
on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transplant related transportation and lodging (S9975) 
provided from July 9, 2023, to July 18, 2023. 
 
You asked the Plan to pay for transplant related transportation and lodging (S9975). You say that these 
expenses were in connection for a transplant evaluation.  The Plan denied your request. The Plan says dates of 
service July 9, 2023, to July 10, 2023, is being upheld as these dates have been approved and processed to you 
prior to your appeal being received. The Plan also says that dates of service July 16, 2023, to July 18, 2023, are 
being upheld because these services were unrelated to your transplant. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which an MA plan 
provides transplant services at a more distant location, the MA plan must provide reasonable transportation for 
the enrollee and a companion to the distant facility; and provide reasonable accommodations for the enrollee 
and a companion while in the distant location for medical care. 
 
We looked at the file and Medicare rules. The record shows that the Plan already paid for the services received 
on dates of service July 9, 2023, to July 10, 2023. The record also shows that the services received on dates of 
service July 16, 2023, to July 18, 2023, were related to a heart problem and not the covered lung transplant. 
Based on this information, we decided that Medicare rules for coverage of transplant related transportation and 
lodging (S9975) have not been met. Therefore, we decided that the Plan does not have to pay for transplant 
related transportation and lodging (S9975) provided from July 9, 2023, to July 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
from June 9, 2023, to June 10, 2023. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that the service is 
incorrect. 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 $350 
copayment for each in-network outpatient hospital observation stay. 
 
You have been asked to pay a $350 copayment for the hospital observation services. This item/service falls 
within the outpatient hospital observation 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 hospital observation services provided from June 9, 2023, to June 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (E1161) and accessories (E0973, 
E2231, E2609, E2617, E2201, E2203, E0956, E0953, E1028, E0955, E0954, E1225, K0108, E0961, E2211, 
E2213, E0971, E0990, K0040). 
 
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is covered if the beneficiarys 
mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. If the 
manual wheelchair base is not covered, then related accessories will be denied as not reasonable and 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 a manual wheelchair and accessories. 
Our reviewer says that the requested wheelchair is not medically necessary. Our physician reviewer found the 
documentation indicates that the enrollee has a mobility deficit, but there are no detailed neuromuscular and 
musculoskeletal objective examination findings supporting the need for this device. There is no objective skin 
evaluation. There are no detailed muscle motor strength tests, range of motion of joint tests, sensory deficits, or 
objective exam supporting that the patient is unable to overcome their mobility limitation with a cane or 
walker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a manual wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a manual wheelchair (E1161) and accessories (E0973, E2231, 
E2609, E2617, E2201, E2203, E0956, E0953, E1028, E0955, E0954, E1225, K0108, E0961, E2211, E2213, 
E0971, E0990, K0040).
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 IRF services requested are medically necessary. The 
Plan denied your request. The Plan says the denial of IRF care is correct.  
 
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 enrollee is medically stable as described above does not need a rehabilitation 
physicians supervision 3 times a week in an IRF. The enrollee does not need intensive therapies consisting of 
at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The 
enrollees rehabilitation needs can be safely provided in an alternate and lower intensity setting such as a 
skilled nursing facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dynasplint therapy device. 
 
You asked the Plan to pre-approve a Dynasplint therapy 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 Dynasplint therapy device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient large-scale long-term studies supporting the need for 
the Dynasplint (E1840) for the enrollee's shoulder condition. Peer reviewed studies investigating mechanical 
stretching devices are limited. There is limited high-quality long-term evidence for the use of low load prolonged duration stretch devices for the shoulder. 
 
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 Dynasplint therapy device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dynasplint therapy device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 87150) rendered on 
November 30, 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 Current Procedural Terminology (CPT) code 87150 XU (8 Units) 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 87150 is "Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed." 
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 laboratory report does not 
include documentation to support rationale of separate billing of a Column 1 code with a Column 2 code, and 
therefore cannot be verified.  
 
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 laboratory services (procedure code 87150) rendered on November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical visits provided on July 31, 2023, and August 1, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON visits. You say that your assigned primary care doctor is not accessible 
to you, and you needed medical services. You feel that this should be covered as you were not able to access 
the network provider.  The Plan denied your request. The Plan says routine medical care from OON providers 
must be authorized in advance to be covered. In this case, these were non-emergent visits with an OON 
provider for which authorization was not requested.  
 
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 medical visits provided on July 31, 2023, and 
August 1, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that genicular nerve ablation is medically 
necessary. The Plan denied your request. The Plan says genicular nerve ablation is not medically necessary.  
 
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 genicular nerve ablation. Our reviewer 
says that the requested genicular nerve ablation is not considered medically reasonable and necessary. Our 
physician reviewer found this is considered an experimental/investigational procedure. It is the subject of 
ongoing clinical trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says it is not reasonable to assume, based on your current level of function, that 
you will improve a lot with a short stay in the IRF setting.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. 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 you 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.