Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a disposable drug delivery system (A4305) and home 
infusion therapy (S9501) provided on May 28, 2020. 
 
You asked the Plan to pay for a disposable drug delivery system and home infusion therapy. You say that this 
should be covered. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the rules state that disposable drug delivery 
systems, including elastomeric infusion pumps are non-covered devices because they do not meet the Medicare 
definition of durable medical equipment. The rules also say that status code "I = Not valid for Medicare 
purposes.
 
We looked at the file and Medicare rules. A disposable drug delivery system is not a covered benefit. Code 
S9501 for home infusion therapy has a status code of I. Based on this information, we decided that Medicare 
rules for coverage of a disposable drug delivery system and home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for a disposable drug delivery system (A4305) and 
home infusion therapy (S9501) provided on May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (33289, 93264). 
 
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is FDA-approved 
and medically necessary. The Plan denied your request. The Plan says this is experimental and the enrollee is 
not a part of the national clinical trial. 
 
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 insertion of a CardioMEMS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according 
to leading authorities and not recommended in current guidelines for the treatment of heart failure. The device 
is considered experimental. 
 
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 insertion of a CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (33289, 93264).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on January 11, 2020 billed 
with codes 15004-58, 28140-58-LT, and 28140-58-59-LT. 
 
You asked the Plan to pay for the surgical services as billed.. You say that it is felt that the billed services 
should be paid. The Plan denied your request. The Plan says the codes at issue are not supported in the records. 
 
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 asked our coding 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 surgical services as billed.. Our reviewer 
says that these codes are not support in the records provided. Our coding reviewer found the definition of code 
28140 is metatarsectomy. The medical records do not include sufficient documentation to validate that a 
metatarsectomy was performed on January 11, 2020, therefore this service cannot be verified. There are 
different codes to describe the services documented in the operative report: For ostectomy of the metatarsal 
head, see 28111-28114; For partial excision of the metatarsal bone, see 28122.  
 
The definition of 15004 is Surgical preparation or creation of recipient site by excision of open wounds, burn 
eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, 
mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of 
infants and children. The medical records provided do not include sufficient documentation to corroborate that 
these services were provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical services as billed. have not been met. Therefore, we decided that 
the Plan does not have to pay for the surgical services provided on January 11, 2020 billed with codes 15004-
58, 28140-58-LT, and 28140-58-59-LT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for physician services provided to the enrollee from 
July 6, 2020 to July 9, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim was submitted with a bill type of 131 and is subject to Outpatient Prospective 
Payment System (OPPS). The Plan states the claim was submitted with an inappropriate bill type code. The 
Plan states a corrected claim is required.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid as 
billed due to an issue with the bill type code. Medicare billing criteria are not met. Therefore, we decided that 
the Plan does not have to pay for to pay for physician services provided to the enrollee from July 6, 2020 to 
July 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being 
provided already in the current acute care setting already approved. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be improving but requires additional short term acute care services only, based on the records, which 
can safely be completed at the current facility. The patient does not require services at the LTACH that are not 
already available at the current facility. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on August 19, 2020. 
 
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 code 71045 is not supported. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32557. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32557. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on August 19, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stocking/sleeve (CPT Code 
A6549). 
 
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Medicare does not cover garments 
unless they are being used to dress a wound or with a medical device. You are not using the arm sleeves for the 
covered reasons. Therefore, we decided that the Plan does not have to pre-approve gradient compression 
stocking/sleeve (CPT Code A6549).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to review the claims for oxygen services provided from August 21, 2019 to December 21, 2019. 
 
You asked the Plan to pay for the oxygen services. You say that the claims were timely. The Plan denied your 
request. The Plan says that the claims were untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows the claims for oxygen services was filed  July 20, 2020. This means that less than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
has to review the claims for oxygen services provided from August 21, 2019 to December 21, 2019. The Plan 
should provide the appellant with a waiver of liability form and instructions for completion. Once a valid 
waiver is received, the plan should complete the plan level review.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on October 28, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services are 
not Payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on October 28, 2019.  
 
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 long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care (LTC) needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery for unlisted surgical procedure of the 
liver (47399) provided May 11, 2020. 
 
You asked the Plan to pay for unlisted surgical procedure. You say that this claim has been denied in error for 
no authorization. Please reprocess accordingly. The Plan denied your request. The Plan says statutory payment 
restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery for unlisted 
surgical procedure of the liver (47399) provided May 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 2, 2020, to 
February 13, 2020. 
 
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 claims were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023-revenue code line 
on which the first four positions of the HIPPS code match the code submitted on the RAP. 
 
We looked at the file and Medicare rules. The claims were not billed with the required 0023 revenue 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 from January 2, 
2020, to February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia - first 15 minutes 
(D9222) and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223 x3). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia - first 15 minutes and deep 
sedation/general anesthesia - each subsequent 15 minute increment. You say that the services are necessary. 
The Plan denied your request. The Plan says the requested services are 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 deep 
sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent 
15 minute increment (D9223 x3).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for laboratory services (83036) provided on October 2, 
2019. 
 
You asked the Plan to hold you harmless for laboratory services. You say that you don't know why you are 
being billed for this service. The Plan denied your request. The Plan says that this service was not billed 
correctly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The laboratory services at issue were provided by a contract provider. The file does not show that the Plan 
provided notice that laboratory services would not be covered. Under Medicare rules, this means laboratory 
services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for 
laboratory services (83036) provided on October 2, 2019.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for left foot cellulitis 
and had a below the knee amputation. The enrollee's medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the documentation provided, you do 
not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have 
documented skilled therapy needs. You are ambulating household distances. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at 
this point, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of diagnostic or therapeutic substance (62321). 
 
You asked the Plan to pre-approve injection of diagnostic or therapeutic substance. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria has 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 injection of diagnostic or therapeutic 
substance. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there are no clear radicular signs and symptoms noted and 
no clear imaging noted showing severe nerve root compression at C4-5 right side. 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 injection of diagnostic or therapeutic substance have not been met. Therefore, 
we decided that the Plan does not have to pre-approve injection of diagnostic or therapeutic substance (62321).