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

 
We decided that the Plan has to pay for laboratory testing (81479) billed for date of service December 22, 
2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that the date of service for a clinical 
laboratory test or the technical component of physician pathology service must be the date the specimen was 
collected. The specimens were collected on May 4, 2021, and November 29, 2021, rather than the billed date of 
service December 22, 2021. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service; however, there are three exceptions to this rule. The rules 
also 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 addressed nor acknowledged the exceptions to the 
rule applied in this case. The record shows that the test in this case was performed on a solid tumor specimen 
which would have been collected during a surgical procedure which needed to be provided in a hospital setting. 
It is very likely that an exception to the general rule has been met in this case, but this possibility has not been 
explored by the Plan. In this case, the correct date of service to report would be the date the testing was 
performed. Therefore, we decided that the Plan has to pay for laboratory testing (81479) billed for date of 
service December 22, 2021.  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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cast supplies (CPT code Q4038) provided on April 7, 
2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. CPT code Q4038 denied per OCE 
Edit 62 for codes that are not recognized by Medicare for OPPS are not paid under OPPS or any other 
Medicare payment system. Per the guidelines, we find the Medicare rule for payment for date of service April 
07, 2022, has not been met. OCE Edit 62 has Return to Provider disposition (RTP) which shows there are one 
or more edits present that cause the whole claim to be returned to the provider therefore, the remaining lines 
denied with reason 0992 - Please correct OCE edit error on other claim line. Therefore, we decided that the 
Plan does not have to pay for the cast supplies (CPT code Q4038) provided on April 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 
(CPT code(s): 36475) and injection of sclerosant; multiple incompetent veins (other than telangiectasia), same 
leg (CPT code 36471). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's records do not show documentation of conservative therapy being tried or 
failing. 
 
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 services. Our physician reviewer 
found coverage criteria require that the symptoms be due to the veins to be treated. This is not possible as there 
has been no pulse examination nor other assessment of lower extremity arterial perfusion. There has to be 
demonstration of absence of peripheral artery disease and the presence of peripheral arterial disease (PAD) is 
an exclusion/limitation. The conclusion of the ultrasound report notes significant reflux at the right great 
saphenous vein (GSV); however, the reflux at that site measures 0 sec. The veins to be treated are exceptionally 
small and the patient complains of joint pain. Therefore, the criterion that the veins be symptomatic is not met. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging 
guidance and monitoring, percutaneous, radiofrequency; first vein treated (CPT code(s): 36475) and injection 
of sclerosant; multiple incompetent veins (other than telangiectasia), same leg (CPT code 36471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair, single power 
option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0837) 22 NF sealed lead acid battery 
(E2361) manual swingaway, retractable or removable mounting hardware for joystick, other control interface, 
or positioning accessory (E1028) power seating system, tilt only (E1002). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are appealing the denial of the 
requested power wheelchair. The Plan denied your request. The Plan says the requested power wheelchair and 
accessories are not medically necessary. The enrollee is able to ambulate in home distances with home oxygen 
and a cane but would more safely do so with a heavy duty 4 wheeled walker with seating as a better alternative. 
 
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 the power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is documentation that this enrollee has a 
personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, 
feeding, grooming and bathing in customary locations within the home. A mobility assessment from July 31, 
2022 reported that the enrollee was able to successfully ambulate 10-20 to 50 feet with a cane within their 
home and that a wheeled walker was recommended for mobility needs. It is not clear that the enrollee can 
safely operate the power mobility device as records document the enrollee is reliant on supplemental oxygen 
due to heart disease, but the enrollee has no portable oxygen supply to use with a power mobility device. 
Without supplemental oxygen available, use of the power wheelchair would not be safe. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 2 heavy duty power wheelchair, single power option, sling/solid 
seat/back, patient weight capacity 301 to 450 pounds (K0837) 22 NF sealed lead acid battery (E2361) manual 
swingaway, retractable or removable mounting hardware for joystick, other control interface, or positioning 
accessory (E1028) power seating system, tilt only (E1002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump provided on 
December 16, 2021, to December 31, 2021. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that the records provided 
support the need for the requested water circulating heat pad with pump. The Plan denied your request. The 
Plan says the item in dispute is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that water circulating heat pad with pump is not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump provided on December 16, 2021, to December 
31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for dates of service October 15, 
2021, to October 21, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that you have provided records to support the 
code billed. 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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for dates of service October 15, 2021, to October 21, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the health plan argues that SNF services are no longer necessary and reports that the 
enrollee can walk 440. No SNF records have been submitted for review. No physical or occupational therapy 
records have been submitted for review. Therefore, the health plan has failed to support its denial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan 
has to pre-approve skilled nursing facility (SNF) care.  
 
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 the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro represents this enrollee's best 
opportunity for regaining meaningful use for his right upper limb and has been deemed medically necessary for 
this enrollee by their provider. The Plan denied your request. The Plan says this device is considered 
experimental and investigational. 
 
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 orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
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 enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found based 
on the medical records provided there is no documentation that this enrollee has a neuromuscular disease, 
thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
Provided records document severe morbid obesity with alveolar/obesity hypoventilation syndrome and chronic respiratory failure but records do not document neuromuscular disease, thoracic restrictive disease, or chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. Records do not include any pulmonary 
function testing showing restrictive or obstructive disease.  
 
Provided records document that the home ventilator is being requested for use in intelligent volume assured 
pressure support (IVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with 
AVAPS and a back-up rate.  As stated in the Local Coverage Determination (L33800): "Claims for ventilators 
used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as 
not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx testing provided on May 17, 2021. 
 
You asked the Plan to pay for the genetic testing at issue. You say that this is Medicare-covered testing that is 
reasonable and necessary for this enrollee. The Plan denied your request. The Plan says that a determination 
was not made on medical necessity because the date of service reported is not correct. Lab claims must always 
use the date of the sample collection as the DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that, while generally the DOS for lab testing is the 
date of specimen collection, exception exist as described in the Medicare rules section.  
 
We looked at the file and Medicare rules. We find that the Plan did not evaluate whether criteria for a DOS 
exception were met. This is a molecular pathology test. The Plan did not provide evidence to show the sample 
was not collected in the outpatient hospital setting. Based on this information, we decided that Medicare rules 
for coverage of the genetic testing at issue have been met. Therefore, we decided that the Plan has to pay for 
the FoundationOne Liquid CDx testing provided on May 17, 2021.  
 
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 laboratory services provided on October 25, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on October 25, 2021, 
by an out-of-network (OON) provider.
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall and nonsurgical management of a humerus fracture. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 80307, 83789-59, and G0481. 
 
You asked the Plan to pay for codes 80307, 83789-59, and G0481. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan that code 83789 is not separately 
payable.  
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. Medicare rules also 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 code 83789-59 have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. In addition, for codes 80307 and 
G0481, 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 billed 
with codes 80307, 83789-59, and G0481.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve a walk-in bathtub. You say that the enrollee needs this. The Plan denied 
your request. The Plan says this is not covered under Medicare rules. 
 
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 walk-in bathtub.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 8, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 an office visit provided on June 8, 2022, by an 
OON provider.