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

 
We decided that the Plan has to pre-approve an expandable controller, harness, and connection for an approved 
group 3 power wheelchair (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the expandable controller, harness, and connection. You say that the 
expandable controller is medically necessary. The Plan denied your request. The Plan says that the enrollee can 
operate the power features using the standard switches. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is medically necessary when 
an enrollee requires the ability to operate 3 or more powered seating actuators through the drive control. 
 
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 expandable controller, harness, and 
connection. Our reviewer says that the requested expandable controller is medically necessary. Our physician 
reviewer found the enrollee cannot perform pressure relief independently due to upper extremity weakness and 
requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The 
enrollee requires power elevating leg rests for positioning of his lower extremities and lower extremity 
spasticity. The expandable controller with harness and electronic connection are necessary to operate the group 
3 power wheelchair base and the three medically necessary power options using the joystick. 
 
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 expandable controller, harness, and connection have been met. Therefore, 
we decided that the Plan has to pre-approve an expandable controller, harness, and connection for an approved 
group 3 power wheelchair (E2311, E2313, E2377).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870 billed for date of service May 9, 2023.  
 
You asked the Plan to pay for procedure code 95870. You say that medical records were provided. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95870 is 4. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided, correctly 
coded, and medically necessary. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95870 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95870 billed for date of service May 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 25, 2023, to 
February 23, 2023. 
 You asked the Plan to pay for the home health services. You say that there was an issue in 2022 with NOAs not 
getting accepted, so you resubmitted it. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 26, 2022. The NOA was not received by the Plan until April 26, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 25, 2023, to February 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an anterior cervical fusion. 
 
You asked the Plan to pre-approve an anterior cervical fusion. You say that the requested procedure is the next 
step in relieving the enrollee's neck pain. The Plan denied your request. The Plan says the inpatient 
hospitalization for anterior cervical decompression and fusion surgery requested does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an anterior cervical fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found more conservative measures are required. The documentation does not 
show a 3-month history of physical rehabilitation.  
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 anterior cervical fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an anterior cervical fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have  to pay for the pneumatic compression device (E0676) provided on 
February 2, 2023. 
 
You asked the Plan  to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have  to 
pay for the pneumatic compression device (E0676) provided on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the NeXT Dx test (81479) provided on October 28, 2022. 
 
You asked the Plan to pay for the NeXT Dx test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS tests must have satisfactorily completed a 
TA by MolDX for the stated indications of the test 
 
We looked at the file and Medicare rules. The DEX Diagnostics Exchange Registry shows that this test is not 
covered. Based on this information, we decided that Medicare rules for coverage of the NeXT Dx test have not 
been met. Therefore, we decided that the Plan does not have to pay for the NeXT Dx test (81479) provided on 
October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on May 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the specific drug testing provided in this case. 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 the drug testing provided on May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2023. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on February 7, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on February 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service April 
15, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was not able to transport himself. 
The Plan denied your request. The Plan says it cannot be determined whether the services were performed. 
 
 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. The documentation does not include transportation records. Based on 
this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for the ambulance transportation billed for date of service April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis procedures (90999, G0491) to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve dialysis procedures to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
dialysis procedures (90999, G0491) 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 Urine Polymerase Chain Reaction (PCR) panel provided 
on November 17, 2022. 
 
You asked the Plan to pay for the Urine PCR panel. You say that the Urine PCR panel testing provided was 
medically necessary. The Plan denied your request. The Plan says the Urine PCR panel testing provided was 
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 Urine PCR panel. Our reviewer says that 
the Urine PCR panel testing provided was not medically necessary. Our physician reviewer found the enrollee 
had no symptoms. A review of the medical literature in clinical practice guidelines, including by the Infectious 
Disease Society of America and Healthcare Infection Control Practices Advisory Committee (HICPAC), state 
that standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine culture 
and susceptibility studies. In addition, there is lack of support for the clinical utility of large multiplex PCR 
urinary tract infection panel tests. 
 
Urine PCR amplification techniques raise considerable concerns regarding contamination from one specimen 
to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also 
be challenging.  Amplification of organisms representing latent infection or colonization cannot be 
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of 
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
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 Urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the Urine Polymerase Chain Reaction (PCR) panel provided on November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87641, 87798, 87640, 87500, 87651, 
87471, 87493, 87529, 87563, 87653, and 87651 billed for March 15, 2023. 
 
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 procedure codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 
87563, 87653, and 87651 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87641 is infectious agent 
detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe 
technique. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. The definition of code 87640 is infectious 
agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique. The 
definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance 
(eg, enterococcus species van A, van B), amplified probe technique. The definition of code 87651 is infectious 
agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique. The 
definition of code 87471 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, 
amplified probe technique. The definition of code 87493 is infectious agent detection by nucleic acid (DNA or 
RNA); Clostridium difficile, toxin gene(s), amplified probe technique. The definition of code 87529 is 
infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique. 
The definition of code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma 
genitalium, amplified probe technique. The definition of code 87653 is infectious agent detection by nucleic 
acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 87651 is 
infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique.  
 
We find that CPT codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 87563, 87653, and 
87651 are not supported in the medical record. Specifically, a panel of testing was performed and there is a 
more appropriate singular code for the services. 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 
procedure codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 87563, 87653, and 87651 
billed for March 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after a left 
shoulder arthroplasty. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically 
necessary. The Plan denied your request. The Plan says inpatient care after the approved elective left shoulder 
arthroplasty is not medically necessary. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the record indicates that the enrollee is scheduled for left total shoulder 
arthroplasty. The record provided does not indicate that the medical condition, safety, or health of the enrollee 
would be significantly and directly threatened if care was provided in a less intensive setting. The initial day 
may be spent in observation until it is clearly expected that an inpatient stay would be required, at which time 
the physician may order inpatient admission. The elements of the coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care to be provided after a left shoulder arthroplasty.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (95810). 
 
You asked the Plan to pre-approve a polysomnography. 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 polysomnography is 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 polysomnography. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found no documentation to support the 
use of Hydrocodone on most days per week for greater than 3 months. The review has determined that the 
enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography (95810).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22870, 22869). 
 
You asked the Plan to pre-approve a Vertiflex 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 Vertiflex 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 no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion 
interspinous spacer at L3-4 and L4-5 levels, in this case, 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22870, 22869).