Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 3000 units of stoma absorptive covers 
(A5083) for the year. 
 
You asked the Plan to pre-approve an additional 3000 units. 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 follows Medicare rules. Medicare rules say that Ostomy Supplies are covered when certain 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 an additional 3000 units. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee reports using 
approximately 12 stoma covers per day. The coverage criteria allow up to 150 stoma covers per month, 
whereas this enrollee is requesting more than double this amount. Therefore, this request does not meet 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 3000 units have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 3000 units of stoma absorptive covers (A5083) for the year.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 29, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized.  

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 laboratory services provided on December 29, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 64483 billed for date of service December 12, 2022. 
 
You asked the Plan to pay for code 64483. You say that this service is not inclusive to the surgeon's 
professional claim. The Plan denied your request. The Plan says you did not bill an appropriate anatomic 
modifier for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers or suppliers shall use anatomic 
modifiers and report procedures with differing modifiers on individual claim lines when appropriate. 
 
In this case, you did not bill code 64483 with any anatomic modifier to indicate where the procedure occurred. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 64483 have not been met. Therefore, we decided that the Plan does not have to pay for code 
64483 billed for date of service December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 11, 2022, billed with 
codes 81272, 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 11, 2022, billed with codes 81272, 81314 and 81345.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17003 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 17003. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 17003 is bundled into payment for code 17110. 
 
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 17003 
is a column II code to column I code 17110. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 17003 billed for date of service June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab test provided on November 7, 2022, billed with code 
87634-59. 
 
You asked the Plan to pay for the lab test as billed. You say that the claim should be paid as billed.  The Plan 
denied your request. The Plan says this code is not supported with modifier -59. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, there is no evidence to support that testing for this pathogen was not reported under one of the other codes billed. Based on this information, we decided that Medicare rules for coverage of services 
billed with a -59 modifier have not been met.  Therefore, we decided that the Plan does not have to pay for the 
lab test provided on November 7, 2022, billed with code 87634-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954). 
 
You asked the Plan to pre-approve a prefabricated post and core. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says the requested 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 Plan's 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 pre-approve a 
prefabricated post and core (D2954).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, 
with or without adjustability (L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee is a very active individual who needs a 
socket replacement and a knee/foot replacement  The Plan denied your request. The Plan says that the 
requested computerized knee exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case.  Our physician 
reviewer found the records show the enrollee is quite active. The requested additions are standard of care for an 
active enrollee. The plan has not provided evidence that the device is not optimal for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), 
an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability 
(L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control 
feature, swing and stance phase, includes electronic sensor(s), any type (L5856).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you need the physical therapy sessions 
because you are in recovery for joint replacement surgery that you had. The Plan denied your request. The Plan 
says this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the Plan. You have had prior extensive 
therapy and the documentation does not reveal that you require the ongoing unique skills of a professional 
therapist to safely and effectively provide treatment. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
You can transition to a home exercise program with the already approved therapy.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) units of skin substitute with Epifix (Q4186, 
15275).  
 
You asked the Plan to pre-approve skin substitute with Epifix. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the request was denied due to lack of 
medical necessity. Epifix is covered when used to treat a diabetic foot ulcer when the wound did not get better, 
the enrollee has diabetes and the enrollee's foot has good blood flow. 
 
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 skin substitute with Epifix. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the enrollee has a history of DM, HTN, HLD, 
CKD, lymphedema, sacral ulcer and chronic leg wounds. She has been treated with IV antibiotics, local wound 
care, IR angioplasty, and incision and drainage. Arterial blood flow to the extremities is normal. She has a left 
medical 3rd toe wound and left plantar wound. Per the Plan coverage criteria, the request was denied due to 
lack of medical necessity. Epifix is covered when used to treat a diabetic foot ulcer when the wound did not 
improve, there is a diagnosis of diabetes and there is adequate blood flow. The review has determined that the 
enrollee does not meet the criteria for coverage. The review has determined that the items/services at issue in 
this case are 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 skin substitute with Epifix have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) units of skin substitute with Epifix (Q4186, 15275).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection pharyngoplasty with Restylane for 
velopharyngeal insufficiency and neural prolotherapy provided on October 13, 2022. 
 
You asked the Plan to pay for injection pharyngoplasty with Restylane for velopharyngeal insufficiency and 
neural prolotherapy. You say that the service was medically necessary. The Plan denied your request. The Plan 
says the injection pharyngoplasty with Restylane for velopharyngeal insufficiency and neural prolotherapy is 
experimental and investigational. 
 
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 injection pharyngoplasty with Restylane for 
velopharyngeal insufficiency and neural prolotherapy. Our reviewer says that the requested injection 
pharyngoplasty with Restylane for velopharyngeal insufficiency and neural prolotherapy is not considered 
medically reasonable and necessary. Our physician reviewer found that based on the medical records provided, 
review of the current peer-reviewed medical literature and the Medicare-approved major drug compendia there 
is no documentation that the injection pharyngoplasty with Restylane meets Medicare criteria for medically 
reasonable and necessary, per Social Security Act, Section 1862(a)1(A). Injection pharyngoplasty with 
Restylane for velopharyngeal insufficiency is not a medically accepted indication for use of Restylane per 
the Medicare-approved major drug compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection pharyngoplasty with Restylane for velopharyngeal insufficiency and 
neural prolotherapy have not been met. Therefore, we decided that the Plan does not have to pay for injection 
pharyngoplasty with Restylane for velopharyngeal insufficiency and neural prolotherapy provided on 
October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for 9 months. 
 
You asked the Plan to pre-approve a home 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 home ventilator for 9 months. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found products classified 
as HCPCS code E0466, when used to provide continuous positive airway pressure (CPAP) or bi-level positive 
airway pressure (PAP) (with or without backup rate) therapy, regardless of the underlying medical condition, 
shall not be paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the 
conditions described in this RAD LCD even though the ventilator equipment may have the capability of 
operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in the Medicare RAD policy will be denied as not reasonable and 
necessary. A bilevel positive airway pressure (BiPAP) device with average volume-assured pressure support 
(AVAPS) (coded as E0471) was not requested. 
 
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 home ventilator for 9 months have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a home ventilator for 9 months.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for PalinGen or PalinGen XPlus, per sq cm rendered on June 21,
2022.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says this is investigational and remains denied.

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 the medical documentation supports that this injured enrollee is suffering with a chronic lower
extremity ulceration to the left lower leg. Skin substitutes including amniotic membrane skin substitutes are
Food and Drug Administration (FDA) approved for chronic nonhealing and or stalled diabetic foot ulcerations
and venous leg ulcerations. The medical documentation enclosed in this case does not advise that this enrollee
is suffering with a stalled chronic leg ulceration. There is no documentation stating that the wound size or area
has remained unchanged after at least six weeks of treatment. Furthermore, there is no documentation of
offloading of this area, elevation of leg, weekly compression dressings to alleviate the lower leg edema, wound
care, and other topical medications and or wound dressings. It is unclear what conservative care has been
performed on this leg ulceration, for how long, and if the ulceration healing has stalled.

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 PalinGen or PalinGen XPlus, per sq cm rendered on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on September 3, 2022. 
 
You asked the Plan to pay for the subsequent hospital care. The Plan denied your request. The Plan says the 
provider did not submit documentation of the surgical procedure.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of subsequent hospital care have been 
met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care provided on 
September 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the member has been with the provider for 
many years, has been previously approved. The Plan denied your request. The Plan says this 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the know error DNA Specimen Provenance Assay billed 
with codes 81266 and 81265 for date of service June 17, 2022. 
 
You asked the Plan to pay for codes 81266 and 81265. You say that you have provided the lab report in support 
of payment for this claim. The Plan denied your request. The Plan says this testing is not covered. The Plan 
must follow Medicare rules. Medicare rules say that the know error DNA Specimen Provenance Assay is a 
statutorily excluded test. Therefore, we decided that the Plan does not have to pay for the know error DNA 
Specimen Provenance Assay billed with codes 81266 and 81265 for date of service June 17, 2022.