Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 1, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says a ventilator is not covered by Medicare for this purpose and the enrollee's 
needs could be met by a bilevel positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on June 22, 2022. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 imaging services rendered 
on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electrical hospital bed rental for ten (10) months 
(CPT code E0260RR). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the clinical information provided does not show the enrollee meets medical necessity 
criteria for this type of hospital bed. 
 
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 DME. Our physician reviewer 
found the documentation does not support that the enrollee has a condition that requires frequent positioning of 
the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory 
infections in a way that an ordinary bed is not able to.  
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a semi-electrical hospital bed rental for ten (10) months (CPT code E0260RR).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 3, 2022, to 
April 1, 2022. 
 
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 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 March 3, 2022. The NOA was not received by the Plan until January 7, 
2021. 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 the home health services 
rendered from March 3, 2022, to April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
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 the vertiflex device is 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve the special supplemental benefits. You say that the supplemental benefits 
are medically necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the special supplemental benefits have not been met. Specifically, the attestation from the provider 
does not show that you are at high risk for hospitalization.  
 
 
 Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the 
chronically ill.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 1, 2022, to 
March 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that an NOA was submitted. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. While you submitted proof of filing an NOA, we find that the 
admission date reported on the claim at issue does not match the date that would be required for the NOA 
which is the first date in 2022. Based on this information, we find that the Medicare rules for payment of the 
claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from March 1, 2022, to March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 that the clinical documentation shows that the enrollee has functional impairments, 
but no complex functional impairments deficits are specified (generalized weakness, confusion) thus the 
enrollee would not be expected to require intense therapy or interdisciplinary team management of rehabilitation in an IRF setting. The clinical documentation shows that the enrollee has chronic comorbidities, 
but no active medical issues that would require inpatient hospitalization during rehabilitation. In conclusion, 
the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. 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 May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig provided on June 30, 2022. 
 
You asked the Plan to pay for the provided services. The Plan denied your request. The Plan says the services 
are excluded from coverage. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare.  
 Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. 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 wig provided on June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 8, 2021, to 
December 15, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported correctly and are supported as billed. The Plan denied your request. The Plan says the 
submitted DRG is not supported in the medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with acute posthemorrhagic anemia (D62). 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that this diagnosis is not supported in the medical record. Our physician reviewer found that 
there was a small amount of serous (non-bloody) drainage from the medial aspect of the amputated stump. The 
hemoglobin was 9.1 and the hematocrit was 28. On December 8, 2021, the enrollee underwent irrigation and 
non-excisional debridement of the left below knee amputation stump with placement of a wound vacuum-
assisted closure (VAC). There was minimal blood loss. On December 10, 2021, the hemoglobin was 8.4 and 
hematocrit was 25.6. On December 14, 2021, the hemoglobin was 8.3 and the hematocrit was 25.4, essentially 
unchanged. In this case there was no clinical or laboratory evidence of acute posthemorrhagic anemia (D62). 
The review has determined that the billing of acute posthemorrhagic anemia (D62) was not supported in the 
medical records provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 8, 2021, to December 15, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair provided on November 12, 2021. 
 
You asked the Plan to pay for the provided device. You say that there should be a 50% reimbursement for 
durable medical equipment. The Plan denied your request. The Plan says there were network providers 
available for the services. 
 
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. 
 
We looked at the file and the rules. The records indicate that the provider at issue is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for the power wheelchair provided 
on November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0652 and full leg sleeve. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an E0652 PCD 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not document 
marked hyperkeratosis with hyperplasia and hyperpigmentation or apillomatosis cutis lymphostatica or 
deformity of elephantiasis or skin breakdown with persisting lymphorrhea or detailed measurements over time 
confirming the persistence of the lymphedema and with a history evidencing a likely etiology. The records do 
not document detailed measurements, obtained in the same manner and with reference to the same anatomic 
landmarks, prior to and at the conclusion of the various trials of conservative treatment and therapy with a basic 
pump. The criteria for coverage are not met and the services are therefore not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) described by code E0652 and full leg sleeve.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI with high intensity focused ultrasound. 
 
You asked the Plan to pre-approve the MRI with high intensity focused ultrasound. You say that the enrollee 
has an essential tremor in their right hand, has a severe cardiac history and is on blood thinners. You say that 
the enrollee does qualify for other aggressive procedures. The Plan denied your request. The Plan says the 
requested service is not covered if you have unstable heart problems.  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 MRI with high intensity focused 
ultrasound. 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 an essential tremor, but the records are 
insufficient to establish that the elements of the coverage criteria are satisfied. The requested service is not 
recommended. 
 
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 MRI with high intensity focused ultrasound have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an MRI with high intensity focused ultrasound.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 93458. 
 
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 93010 
is a column II code to column I code 93458. 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 93010 billed for date of service August 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. 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 CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
record indicates that the enrollee has had imaging including a magnetic resonance imaging (MRI) of the 
abdomen and endoscopic ultrasound demonstrating dilated pancreatic duct. A CT scan of the abdomen has 
been performed in November 2022. The provided records do not indicate the medical necessity or 
reasonableness, as defined by Medicare rules, of the requested service at this time. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. 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 bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bioimpedance spectroscopy devices for detection of lymphedema are 
considered investigative and unproven. There is insufficient reliable evidence in the form of high quality peer-
reviewed medical literature to establish the efficacy or effects on health care outcomes. 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 bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracorporeal photopheresis services provided on June 
2, 20222. 
 You asked the Plan to pay for the provided services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the service was not provided for a covered indication. 
 
The Plan must follow Medicare rules. Medicare rules say that extracorporeal photopheresis is only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee was part of a Medicare 
covered clinical research study. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the extracorporeal photopheresis 
services provided on June 2, 20222.