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

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), expandable controller (E2377), harness for upgrade to 
expandable controller (E2313), and attendant control (E2331). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, harness, and attendant 
control. 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 an electronic connection, expandable 
controller, harness, and attendant control. 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 
sufficient strength and function in upper extremities to manage standard power drives. Additionally, attendant 
control may not be added if there is operator control. 
 
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 electronic connection, expandable controller, harness, and attendant control 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), expandable controller 
(E2377), harness for upgrade to expandable controller (E2313), and attendant control (E2331).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
October 28, 2022. 
 
You asked the Plan to pay for procedure codes 20936 and 20930. You say that you have provided the operative 
report to support payment. The Plan denied your request. The Plan says procedure codes 20936 and 20930 are 
considered bundled and not separately payable.  
 
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 codes 20936 and 20930 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20936 and 20930 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20936 and 20930 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 20, 2023, billed with 
codes 81227, 81230, 81231, 81232, 81240, 81241, 81306, 81328, 81335, 81355, and 81291. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing assesses how a patient may 
respond to prescribed drugs. 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. 
 
The file shows that a pharmacogenomics test panel was provided. We looked at the file and Medicare rules. 
This NGS panel was not billed with a single 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 April 20, 2023, billed with codes 81227, 81230, 81231, 
81232, 81240, 81241, 81306, 81328, 81335, 81355, and 81291.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service April 12, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment 
for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87498, 87502, U0003, U0005, and 
87634 for date of service February 7, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87498, 87502, U0003, U0005, and 87634. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. The rules say that a panel cannot be unbundled and billed as individual 
components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We find that 14 units of CPT code 87798 are not supported in the medical record. The medical record only 
supports 11 units of CPT code 87798 as only 11 units were tested. Review of the file shows that codes 87498, 
87502, U0003, U0005, and 87634 were individually submitted but should have been submitted as a bundled 
code. This means the codes are not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 87798, 87498, 87502, U0003, U0005, and 87634 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87798, 87498, 87502, U0003, 
U0005, and 87634 for date of service February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 21, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup on tooth #23 (D2950). 
 
You asked the Plan to pre-approve a core buildup on tooth #23. You say that this is medically necessary. The 
Plan denied your request. The Plan says the criteria for a core buildup (D2950) #23 has not been met because 
there will be adequate remaining tooth structure after the decay is removed to retain a crown. 
 
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 core buildup on tooth #23. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a review of the submitted documentation indicates that tooth #23 appears to 
have adequate coronal structure to provide support and retention for a crown restoration without the need or a 
core buildup. 
 
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 core buildup on tooth #23 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a core buildup on tooth #23 (D2950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided by an out-of-
network provider on May 24, 2023, and June 14, 2023. 
 
You asked the Plan to waive the cost sharing for the office visits. You say that these services are supposed to 
be covered. 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. Your 
contract with the Plan says that there is a $1,500 deductible which applies to the out-of-network office visits. 
 
You have been asked to pay a $187.48 deductible for the office visits ($93.74 deductible x 2 visits = $187.48). 
The items or services you asked the Plan to waive the cost sharing for were provided by an out-of-network 
provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 
deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is 
a contractual obligation that had not been met at the time the office visits were received on May 9, 2023, and 
June 14, 2023. Therefore, we decided that the Plan does not have to waive the cost sharing for the office visit 
provided by an out-of-network provider on May 24, 2023, and June 14, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve cardiovascular stress tests identified with codes 93015, 93016, 
93017, and 93018 and myocardial perfusion imaging identified with code 78452. 
 
You asked the Plan to pre-approve cardiovascular stress tests and myocardial perfusion imaging. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says that the requested services are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular stress tests and myocardial imaging is 
covered for certain indications. 
 
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 cardiovascular stress tests and 
myocardial perfusion imaging. Our reviewer says that the documentation does support that the requested 
services are medically reasonable and necessary. Our physician reviewer found you have angina and history of 
pacemaker as well as a myocardial infarction. Cardiac echo has revealed aortic regurgitation. You do have 
angina and prior myocardial infarction together with pacer and aortic regurgitation. Your complex cardiac 
history qualifies you for the requested nuclear medicine stress test. Therefore, you meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiovascular stress tests and myocardial perfusion imaging have been met. 
Therefore, we decided that the Plan has to pre-approve cardiovascular stress tests identified with codes 93015, 
93016, 93017, and 93018 and myocardial perfusion imaging identified with code 78452.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient level of care. 
 
You asked the Plan to pre-approve the inpatient level of care. You say that the enrollee needs surgery. You say 
that the enrollee has tried physical therapy. You also say that it did not help. The Plan denied your request. The 
Plan says there is no documentation to support the expectation that the enrollee will need a greater than 2 
midnight stay for this procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the inpatient level of care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission has been met in this case. 
Our physician reviewer found there is no documentation provided indicating the need for an inpatient 
admission for the elective procedure. The enrollee is medically stable and has been provided medical clearance. 
The procedure is not listed on the CMS Inpatient Only List. Therefore, the reviewer found that the record does 
not show that at the time of inpatient admission it was reasonable for the admitting physician to expect that the 
patient's necessary hospital care would span two midnights with supporting documentation of the patient's 
history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 inpatient level of care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an accent color kit (K0108) and a leatherette cushion 
(K0108). 
 
You asked the Plan to pre-approve an accent color kit and a leatherette cushion. You say that these items are 
necessary. The Plan denied your request. The Plan says these items are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve an accent color kit (K0108) and a leatherette cushion 
(K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty at T11, T12, and L1. 
 
You asked the Plan to pre-approve the kyphoplasty at T11, T12, and L1. You say that  the enrollee's quality of 
life is at a zero as they are in constant pain and needs help.  The Plan denied your request. The Plan says  the 
kyphoplasties 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 pre-approve the kyphoplasty at T11, T12, and L1. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found was being treated for collapsed vertebra not elsewhere classified. However, 
detailed documentation is not evident regarding osteoporosis or treatment for such. The provided 
documentation does not corroborate acute/subacute compression fractures at T11 and T12 and there is no 
indication of an L1 fracture. Additionally, there is no documentation of a progression of the body height loss, 
greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. 
Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible causes of pain. 
Therefore, the enrollee does not meet criteria for the kyphoplasties. 
 
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 at T11, T12, and L1 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the kyphoplasty at T11, T12, and L1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, 
E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2603, E2620, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. 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 power mobility devices are covered when specific 
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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
there is insufficient information in the power mobility evaluation to support a group 3 power wheelchair with 
power tilt & recline, power elevating leg rests and power seat elevator. The enrollee is noted to be non-
ambulatory, but it is not clear what her actual level of mobility is and if she is functionally non-ambulatory or 
requires a manual wheelchair for mobility. There is incomplete graded motor strength with regards to her upper 
and lower extremities. She is noted to have a history of skin breakdown but the extent and staging of this is not 
provided. Her level of independence with transfers is not provided and it is unclear if she will be independent 
with transfers with a power seat elevator. This information needs to be provided for a group 3 power 
wheelchair base and the requested power components. Although the enrollee is noted to have a history of a 
stroke with hemiplegia, a group 3 power wheelchair base is typically indicated in patients with significant 
paralysis due to conditions such as a spinal cord injury. 
 
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 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, E1007, 
E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2603, E2620, K0861).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided April 3, 2023, billed with 
codes 87150, 87481, 87641, 87653, 87798, 87801. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. The PCR testing is considered excessive and not medically necessary. 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 Urine PCR panel provided April 3, 2023, billed with codes 87150, 
87481, 87641, 87653, 87798, 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the electrical stimulation 
(G0283) provided from June 5, 2023, through June 21, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
  
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) and the electrical stimulation (G0283) provided 
from June 5, 2023, through June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 67028 provided on May 16, 2023. 
 
You asked the Plan to pay for procedure code 67028. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 67028 is not supported in the medical record. This code has a bilateral surgery indicator 
of 1. This means the code should be reported with 1 unit of service and modifier 50 (bilateral modifier) or an 
appropriate anatomical modifier (right or left) to be considered for payment. Based on this information, we 
decided that Medicare rules for coverage of procedure code 67028 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 67028 provided on May 16, 2023.