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

 
We decided that the Plan does not have to pay for the lab services provided on August 11, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no 
documentation of the order. 
 
 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. In this case, there is no order from the treating physician that 
indicates what specific labs were needed. 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 lab services 
provided on August 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the targeted case management services (T1017). 
 
You asked the Plan to pre-approve the outpatient services. You say that you are requesting an appeal for 
authorization of targeted case management. The Plan denied your request. The Plan says the enrollee does not 
meet all requirements for targeted case management certification. 
 
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 outpatient services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on review the records provided, documentation does not show on impairment 
in this enrollee taking medications prescribed and the ability to participate in their healthcare. Based on review the records provided, this enrollee does not require targeted case management services for the treatment of their 
mental health disorder as it is not considered medically necessary or reasonable. 
 
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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the targeted case management services (T1017).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the nail debridement (11721) provided on January 24, 2022. 
 
You asked the Plan to pay for the routine foot care. You say that the enrollee did not have a choice as to which 
provider they saw. You also say that this should be paid. The Plan denied your request. The Plan says that this 
cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not indicate how much of the enrollee's deductible had 
been mat at the time. Therefore, we decided that the Plan has to pay for the nail debridement (11721) provided 
on January 24, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on May 05, 2022. 
 
You asked the Plan to pay for an x-ray. You say that this was medically necessary and should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an x-ray provided on 
May 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on March 7, 2022. 
 
You asked the Plan to pay for the testing services. You say that medical records were provided. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 
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 the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on March 7, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on September 19, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that your facility is enrolled with 
Medicare and you provided the Medicare enrollment letter. The Plan denied your request. The Plan says that 
Medicare does not cover services that are not performed by a Medicare-certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a rule to substantiate their denial. The 
Medicare letter that has been provided is proof that this facility is approved to participate in Medicare during 
the COVID-19 Public Health Emergency. Therefore, we decided that the Plan has to pay for an emergency 
department visit provided on September 19, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on September 14, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and were 
reported correctly. The Plan denied your request. The Plan says that the reported code is not supported for the 
services provided. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records support that 
between 15-21 drug classes were tested in this case, including amphetamines, benzodiazepines, buprenorphine, 
cannabinoids (natural), cocaine, heroin metabolite, methadone, methylenedioxyamphetamines, 
methylphenidate, opiates, opioids and opiate analogs, oxycodone, phencyclidine, pregabalin, skeletal muscle 
relaxants, tapentadol and tramadol. Based on this information, we decided that Medicare rules for coverage of 
drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug testing (G0482) 
provided on September 14, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee is heavy set and suffers from 
Alzheimers. This chair will help you when you have to take the enrollee to doctor appointments. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria. 
 
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.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your 
condition can be improved by a walker, cane or manual wheelchair and the records do not show that you can 
safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 5, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services are supported in the medical 
records. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 44005 and 44602 provided to the enrollee 
on August 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is:  
CPT 44005: 
 
Enterolysis (freeing of intestinal adhesion) (separate procedure) 
 
CPT 44602: 
 
Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single 
perforation 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 44602 is not supported 
by the medical record. The procedure note states that an enterotomy was performed, or an intentional incision 
of the small intestine, to decompress it. There is no mention of an ulcer, diverticulum, wound, injury, or 
rupture. CPT code 44602 should only be used to report repair of an ulcer, diverticulum, wound, injury, or 
rupture, per the code description. Since these elements of the code description were not present, the CPT code 
44602 is not supported. 
 
Additionally, in this case, we have confirmed that code 44005 is a column II code to column I code 44602. 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.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 44005 and 44602 provided to the enrollee on August 15, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0427, A0425) provided on August 
5, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this transport was medically necessary and 
should be paid. The Plan denied your request. The Plan says that the payment for these services was included in 
the hospital payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no documentation to support that this 
transport was considered patient transportation and would be included in a facility payment. The Plan's denial 
is not substantiated without this supporting documentation. Therefore, we decided that the Plan has to pay for 
ambulance transportation services (A0427, A0425) provided on August 5, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for the hospital outpatient clinic visit for assessment and management of a 
patient (G0463). 
 
You asked the Plan to pay for the outpatient visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that prior authorization was not obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the outpatient visit. Our reviewer says that 
the outpatient visit is considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided documentation indicates that the evaluation was medically necessary and indicated for the 
evaluation and treatment of his medical conditions. Therefore, the reviewer found that the outpatient visit was 
medically reasonable and 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 the outpatient visit have been met. Therefore, we decided that the Plan has to 
pay for the hospital outpatient clinic visit for assessment and management of a patient (G0463).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the device should be covered as durable 
medical equipment. The Plan denied your request. The Plan says the request is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliance 
provided on July 20, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and appliance provided on July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliance 
provided on September 9, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and appliance provided on September 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vestibular evoked myogenic potential (VEMP) testing 
(92517). 
 
You asked the Plan to pre-approve VEMP testing. The Plan denied your request. The Plan says there is not 
enough evidence to show that VEMP testing has clinical utility for patients with vestibular disorders including 
but not limited to benign paroxysmal positional vertigo. The Plan also says the use of VEMP testing is 
considered investigational for any indication and therefore is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve VEMP testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the literature is insufficient to support the medical necessity of the requested service for the 
enrollee's condition as documented in the medical records. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. Our reviewer found that 
the elements of the coverage criteria are not satisfied. Our physician reviewer also found that 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 VEMP testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vestibular evoked myogenic potential (VEMP) testing (92517).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fitness watch. 
 
You asked the Plan to pre-approve a fitness watch. You say that you have high blood pressure and heart 
problems. The Plan denied your request. The Plan says a fitness watch is not used to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a fitness watch.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247 and 75710 provided to the enrollee 
on July 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 36247: 
 
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family 
 
 
 CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support that the codes in question were separate and distinct from the index procedure - namely CPT 37224. 
This code includes the work involved in catheterization and imaging. Diagnostic angiography such as 75710 
can sometimes be separately reportable if a complete angiogram is performed and documented and the 
intervention is based on that study and that no recent angiogram has been performed. In this case, a complete 
lower extremity angiogram is not included as the inflow all the way to the superficial femoral artery (SFA) is 
unknown. It is not documented that no recent angiography has been performed.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 36247 and 75710 provided to the enrollee on July 28, 2022.