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

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 15, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the Plan's denial. 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 March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 25, 
2023.  
 
You asked the Plan to pay for procedure code 81456. 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 April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 for date of service 
August 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
81479 for date of service August 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the panniculectomy. 
 
You asked the Plan to pre-approve the panniculectomy. You say that the enrollee gets chronic rashes which are 
pruritic as well as malodorous. You say that the enrollee has tried and failed multiple ointments. You also say 
that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that panniculectomy is considered medically reasonable 
and necessary when the pannus or panniculus hangs below the level of the symphysis pubis causing chronic 
intertrigo that consistently remains refractory to appropriate medical therapy over a period of three months. 
 
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 panniculectomy. Our reviewer says 
that the requested panniculectomy is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has had weight loss following bariatric surgery. The record does document the 
presence of chronic intertrigo refractory to conservative treatment or stability of weight for six months. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. Therefore, the reviewer found that the requested panniculectomy is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the panniculectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 22, 2023, billed with 
codes 87481, 87500, 87640 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 22, 2023, billed with codes 87481, 87500, 87640 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 for date of service May 12, 2023. 
 
You asked the Plan to pay for procedure code 99222. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 99222 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 minutes must be met or exceeded. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, this service was billed with 
place of service 23 (emergency room- hospital). It is inappropriate to bill code 99222 with place of service 23. Based on this information, we decided that Medicare rules for coverage of procedure code 99222 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99222 for date of service 
May 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 1, 2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI edit was made in error. 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. Any potential changes to the modifier indicator 
were not in effect at the time of service or when the claim was submitted. Based on this information, we have 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 81456 billed for date of service May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair (K0837) and 
additional items and accessories (codes 1012, E2377, E2311, E1002, E2313, E1028, E2341, E2342, E2608, 
E2621, and E2361 x2). 
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair and additional items and 
accessories. You say that you would like this request for the customized wheelchair to be overturned. The Plan 
denied your request. The Plan says the requested wheelchair is not deemed medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 group 2 heavy duty power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has impaired mobility secondary to osteoarthritis and 
excess weight. They live in a long-term care facility and are dependent on lifts for toileting and transfer. Our 
reviewer found that the enrollee is able to eat and do upper body grooming independently. The power 
wheelchair will not increase the enrollee's MRADLs. Our physician reviewer also found that the enrollee has 
access to someone who can push a wheelchair distances. 
 
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 group 2 heavy duty power wheelchair and additional items and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty 
power wheelchair (K0837) and additional items and accessories (codes 1012, E2377, E2311, E1002, E2313, 
E1028, E2341, E2342, E2608, E2621, and E2361 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) denervation (radiofrequency 
ablation (RFA)). 
 
You asked the Plan to pre-approve SIJ denervation. You say that you have exhausted all steroid shots and 
ablation is the next step to relieve pain. The Plan denied your request. The Plan says that SIJ denervation is not 
considered reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ denervation is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SIJ denervation have not been met. Therefore, we decided that the Plan does not have to pre-
approve sacroiliac joint (SIJ) denervation (radiofrequency ablation (RFA)).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service February 17, 
2023.  
 You asked the Plan to pay for procedure code 99291. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 18, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. 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. the NCCI has agreed to 
change the NCCI indicator to 1, which would allow payment for these two codes together. Therefore, we 
decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 18, 2023.
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 this service was billed appropriately and is 
separately payable. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on June 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the records do not support the billed HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims are paid based on HIPPS 
codes. 
 
We looked at the file and Medicare rules. The file shows that the records do not support the billed HIPPS code. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered on June 25, 
2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room individual counseling for substance abuse 
treatment provided April 10, 2023, to April 11, 2023. 
 
You asked the Plan to pay for the emergency room individual counseling for substance abuse treatment. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the provider did 
not submit semi-private room rate. 
 
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 states that these services are denied due to the provider did not submit 
semi-private room rate. In addition, the Plan states that the claim was submitted with a revenue code of 0120 
with a value code of 02, rate amount of $0. The claim does not show a rate amount of $0. No Medicare rules 
were provided to show that no payment could be made on this revenue and value code. No other denial 
rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to 
pay for the emergency room individual counseling for substance abuse treatment provided April 10, 2023, to 
April 11, 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 pre-approve an L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve the kyphoplasty. You say that the enrollee has a compression fracture of L1 
with delayed healing. You also say that this is medically necessary. The Plan denied your request. The Plan 
says the records indicate multiple possible causes for the enrollee's pain. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered when all  the inclusion criteria are met and none of the exclusion criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the kyphoplasty. Our reviewer says that 
the requested kyphoplasty is not medically necessary. Our physician reviewer found the provided 
documentation is not evident regarding significant and ongoing worsening of pain. The reviewer found that 
there is no documentation of a progression of the body height loss, kyphotic deformity, or a severe impact on 
daily activities. There is magnetic resonance imaging (MRI) corroboration of other plausible causes of pain, 
along with plausible fracture retropulsion. Therefore, the reviewer found that the requested L1 kyphoplasty is 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an L1 kyphoplasty (22514).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) services to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON CTA services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says medically necessary care is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography angiography (CTA) services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E1007, E1012, 
E2361, E2607, and E2620). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that there is no other chair on the market that can meet the enrollee's needs. The Plan denied your 
request. The Plan says the enrollee does not have medical need for multiple power options included with a 
K0861 group 3 power wheelchair. The Plan also says that the electronic connection, harness, expandable 
controller cannot be covered as it is not medically necessary to control the three requested power options 
through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as 
code K0861) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee had a stroke and has contractures in their right hand. They 
currently use a manual wheelchair but is limited. Our reviewer also found that the enrollee does not have high 
risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of 
managing power drive. 
 
 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 Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E2311, E2313, 
E2377, E1007, E1012, E2361, E2607, and E2620).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants for 5 teeth that require extractions. 
 
You asked the Plan to pre-approve the dental services. You say that the denied implants would help you 
swallow better, and dentures would affect your sleep. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the dental provider recommended an upper and lower partial 
denture. 
  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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the dental implants are not medically necessary. Our physician reviewer found that the documentation 
indicates that the enrollee's provider recommended the extraction of multiple teeth due to non-restorable caries 
and the placement of removable prostheses. The enrollee wants implants but due to poor enrollee compliance 
with respect to oral hygiene the provider does not feel that the prognosis for implants would be the 
recommended treatment.  Implants require the same patient care as natural teeth or failure will occur. 
Placement of removable prostheses is medically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve dental implants for 5 teeth that require extractions.