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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre CGM reader. 
 
You asked the Plan to pre-approve a CGM reader. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related supplies 
have 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 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre CGM reader.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer to an 
LTACH. You say that the enrollee requires intensive skilled services that are not available at a lower level of 
care. The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
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 that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee requires the requested device 
for the treatment of severe COPD and chronic respiratory failure. The Plan denied your request. The Plan says 
the request for a home mechanical ventilator set in VAPS mode with Auto-EPAP (AE) that could be delivered 
by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from obesity hypoventilation syndrome in the setting of morbid obesity without 
evidence of thoracic restrictive disease. The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine with AVAPS capability. The plan has indicated coverage for such a device is available upon 
request. 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 07, 2021, through 
November 09, 2021, and billed with diagnosis code E87.1. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis E87.1 is supported by the records. The Plan denied your request. The Plan says that the 
documentation submitted does not support secondary diagnosis of E87.1. 
 
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 secondary diagnosis code E87.1-Hypo-osmolality 
and hyponatremia. 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 the documentation does not support the secondary 
diagnosis of E87.1. Our physician reviewer found The member had mild hyponatremia upon presentation. The 
member's condition was noted and monitored by the treating physician. With that being said, diagnosis code 
E87.1-Hypo-osmolality and hyponatremia is the correct secondary diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on November 07, 2021, through November 09, 2021, and billed with diagnosis code 
E87.1.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Lovenox injections. 
 
You asked the Plan to pre-approve Lovenox. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Lovenox 
injections.  
 Benefits for Lovenox may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leucovorin calcium (J0640), fluorouracil (J9190), 
irinotecan (J9206), and oxaliplatin (J9263). 
 You asked the Plan to pre-approve the drugs. You say that this regimen is medically necessary for the enrollee's 
treatment. You also say that this is not a part of a clinical trial. The Plan denied your request. The Plan says 
routine costs associated with a clinical trial cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the drugs as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve leucovorin calcium (J0640), fluorouracil (J9190), irinotecan (J9206), and oxaliplatin (J9263).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. 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 July 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on November 10, 2022. You asked the Plan to pay for laboratory services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says there is insufficient information to support these services. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the provider signature on the test requisition form is illegible, and there are no other medical 
records or progress notes from the referring provider to support the intent to perform this test or support 
medical necessity. Therefore, we decided that the Plan does not have to pay for laboratory services (81479) 
provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94060, 94729, 94726, and 94375 billed for 
date of service June 20, 2022. 
 You asked the Plan to pay for procedure code(s) 94060, 94729, 94726, and 94375. You say that you disagree 
with the denial. The Plan denied your request. The Plan says these codes are included in the skilled nursing 
facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that the services were provided to the enrollee while a SNF inpatient. Per the Physician 
Fee Schedule, CPT codes 94060, 94729, 94726, and 94375 have a Professional/Technical indicator of 1. This 
means that CPT codes 94060, 94729, 94726, and 94375 have both a professional and technical component. In 
this case, CPT codes 94060, 94729, 94726, and 94375 have not been billed with an appropriate modifier to 
indicate the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure code 94060, 94729, 94726, and 94375 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code(s) 94060, 94729, 94726, and 94375 billed for date of service June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous conscious sedation/analgesia, first 15 
minutes (D9239), intravenous conscious sedation/analgesia, each subsequent 15 minutes (D9243), and 
alveoloplasty not in conjunction with extractions (D7321). 
 
You asked the Plan to pre-approve intravenous conscious sedation/analgesia and alveoloplasty. You say that 
you need this service prior to getting dentures. The Plan denied your request. The Plan says these services are 
not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested alveoloplasty is not 
among those covered under this benefit. Since the alveoloplasty is not covered, the anesthesia is not a covered 
service. Therefore, we decided that the Plan does not have to pre-approve intravenous conscious sedation/analgesia, first 15 minutes (D9239), intravenous conscious sedation/analgesia, each subsequent 15 
minutes (D9243), and alveoloplasty not in conjunction with extractions (D7321).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services should be covered as 
continuation of therapy. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray and immunization rendered on September 19, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Procedure codes 73090 and 90471 have an OPPS status indicator of 
Q1(S) and were billed with code 99283. Code 99283 has an OPPS status indicator of V. Codes 73090 and 
90471 are not separately payable when billed with a code with an OPPS SI of V. Therefore, we decided that the 
Plan does not have to pay for the x-ray and immunization rendered on September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 0089U and 81345 provided 
on April 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that based on the information provided along 
with the supporting documentation that clearly shows medical necessity per Medicare criteria, you request 
overturning of the denial and reprocessing of the claim according to CMS guidelines. The Plan denied your 
request. The Plan says enrollee's must receive their medical care from an in-network provider. Prior 
authorization must be obtained prior to receiving services from an out of network provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 0089U and 81345 
provided on April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport rendered on March 3, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that providers must report revenue code 540 for procedure 
codes A0431 and A0436. 
 
We looked at the file and Medicare rules. The file shows that procedure codes A0431 AND A0436 were not 
billed with required revenue code 540. 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 air 
ambulance transport rendered on March 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428-HN, A0425-HN) provided on 
October 22, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this claim was denied in error and should be 
paid. 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 November 2, 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 ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0428-HN, A0425-HN) 
provided on October 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from February 16, 2021, to  
March 9, 2021. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider type is 
not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided from February 16, 2021, to  
March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oncology (tumor of unknown origin) mRNA gene 
expression of 92 genes (81540) provided March 1, 2021. 
 
You asked the Plan to pay for the genetic panel testing. You say that the treating provider ordered the 
CancerType ID test as a safe and effective method to aid in evaluating cancer treatment options for the 
enrollee. The Plan denied your request. The Plan says this code is listed as a Tier 1 non-covered code and is 
denied automatically as 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic panel testing have not been met. Therefore, we decided that the Plan does not have to 
pay for Oncology (tumor of unknown origin) mRNA gene expression of 92 genes (81540) provided March 1, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 63048 provided on October 18, 
2022. 
 
You asked the Plan to pay for two units of procedure code 63048. You say that the operative report is attached, 
and the claim should be reprocessed. The Plan denied your request. The Plan says procedure code 63048 was 
billed without an appropriate primary procedure code.  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 63048 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for two units of procedure code 63048 provided on October 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on October 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this was a wellness visit and you should not 
have been billed. The Plan denied your request. The Plan says that the claim was submitted with the correct 
diagnosis code after review of the provided medical records. 
 
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 valid Medicare rule, a Plan rule or a 
coding rule to substantiate their denial. Therefore, we decided that the Plan has to pay for laboratory services 
provided on October 6, 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.