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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet approval for the requested 
device. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of COPD and 
pulmonary fibrosis, with chronic cough. There is no diagnosis of cystic fibrosis, bronchiectasis documented on 
chest CT, or neuromuscular disease. There is insufficient evidence that this treatment is safe and effective in 
the treatment of COPD or pulmonary fibrosis. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93042 is bundled into payment for code 12051. 
 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 93042 
is a column II code to column I code 12051. 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 93042 billed for date of service July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20950 billed for date of service August 12, 
2022. 
 
You asked the Plan to pay for procedure code 20950. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 20950 is 2. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 20950 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 20950 billed for date of service August 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided August 1, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the prescribing physician recommends an 
extended lifetime use of equipment as they are diagnosed with chronic pain and compromised mobility without 
the option for surgical correction. The Plan denied your request. The Plan says evidence of misrepresentation 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the documentation submitted did not include a 
valid proof of delivery, or a delivery ticket. The submitted packing slip and proof of deliver belong to date of 
service February 01, 2022. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96372 and 64450 billed for date of service 
August 25, 2022. 
 You asked the Plan to pay for procedure codes 96372 and 64450. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for codes 96372 and 64450 is bundled into 
payment for codes 64450 and 55700. 
 
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 codes 
96372 and 64450 are column II codes to column I codes 64450 and 55700. 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 codes 96372 and 64450 billed 
for date of service August 25, 2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was independent prior to hospitalization 
and requires intensive acute rehabilitation to return home safely to the prior level of independence. The Plan 
denied your request. The Plan says there is no documentation that the enrollee has complex medical, nursing or 
rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Medically necessary care may be provided safely in a different 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 in the Medicare rules section. 
 
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. Our physician reviewer found there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71046, 74018) provided on August 23, 
2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 13, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (71046, 74018) provided on 
August 23, 2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you need this level of care. The Plan denied your 
request. The Plan says the records received does not indicate you need an intensive therapy program with 
multiple visits from a rehabilitation doctor per week. Further care could be safely provided by home health care 
or a at a long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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. Our 
physician reviewer found there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
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.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on December 30, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not supported. 
 
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 enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on December 30, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 30, 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 August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker purchased on July 27, 2022. 
 
You asked the Plan to pay for a walker. You say that you should be reimbursed for this. The Plan denied your 
request. The Plan says this was not purchased from a supplier that participates in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a walker purchased on July 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 
You asked the Plan to pre-approve home health services. You say that you cannot lift anything, cook, or pick 
anything up with your dominant hand. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration.  The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, 
E1007, E1012, E2311, E2361, E1028, E2377, E2313, E0955, E1028, K0040, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee does in fact 
meet Medicare criteria as only one recline option is to be met. He has a diagnosis for hemiplegia which 
qualifies him for a group 3 base since it is a neurological condition that causes paralysis. The enrollee has 
spasticity, which is clearly stated in the physical therapy evaluation, which qualifies him for the recline. The 
enrollee does in fact need this wheelchair based on his diagnosis and comorbidities in order to help improve his 
quality of life. The Plan denied your request. The Plan says the enrollee does not have a medical need for 
multiple power options included with a group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
neurologic disorder with functional deficits. Criteria for a power wheelchair are met. The documentation 
available for review does not support that the specifically requested power wheelchair is medically necessary. 
The documentation does not indicate that the enrollee has any pressure injuries, spasticity or requires 
intermittent catheterization of the bladder that would necessitate power tilt or recline. 
 
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 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 (K0861, E1007, E1012, 
E2311, E2361, E1028, E2377, E2313, E0955, E1028, K0040, E2607).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6212 provided on September 2, 2022. 
 
You asked the Plan to pay for procedure code A6212. 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. 
Providers must report services with the appropriate CPT code. 
 
We find that code A6212 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not 
have to pay for procedure code A6212 provided on September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with enclosed frame. 
 
You asked the Plan to pre-approve a walker with enclosed frame. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for a walker with an 
enclosed frame (E0144) has not been established. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a walker with enclosed frame have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a walker with enclosed frame.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99205, 99211, 99215) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits 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 
office visits (99205, 99211, 99215) to be provided by an out-of-network (OON) provider.