Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for lower intestinal endoscopic procedures, endoscopy 
introduced distal to duodenum; not otherwise specified (code 00811) provided on December 22, 2021. 
 
You asked the Plan to pay for anesthesia. You say that the services were medically necessary. The Plan denied 
your request. The Plan says that the anesthesia services always requires an authorization. 
 
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 us with a rule to support their denial. 
Therefore, we decided that the Plan has to pay for anesthesia for lower intestinal endoscopic procedures, 
endoscopy introduced distal to duodenum; not otherwise specified (code 00811) provided on  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341, 88342, 88360, and 88381 billed for 
date of service January 11, 2022. 
 You asked the Plan to pay for procedure code 88341, 88342, 88360, and 88381. You say that you disagree with 
the denial. The Plan denied your request. The Plan says this code is 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 this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88341, 88342, 88360, and 88381 has a Professional/Technical indicator of 1. This means 
that CPT code 88341, 88342, 88360, and 88381 has both a professional and technical component. In this case, 
CPT code 88341, 88342, 88360, and 88381 has 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 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88341, 88342, 88360, and 88381 billed for date of service January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy-duty power wheelchair. 
 
You asked the Plan to pre-approve a group 2 heavy-duty power wheelchair. 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 follows Medicare rules. Medicare rules say that all of the following basic criteria (A-C) must be met 
for a power mobility device or a push-rim activated power assist device (E0986) to be 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 group 2 heavy-duty power 
wheelchair. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based on the medical records provided there is no documentation that the heavy-duty group 2 power wheelchair 
with patient weight capacity 301 to 450 pounds at issue in this case meets all of Medicare's LCD criteria for 
medically reasonable and necessary for you. Provided records document your weight as 270 pounds. As stated 
in the LCD, criteria for coverage are as follows: "The beneficiary's weight is less than or equal to the weight 
capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower 
weight class POV - i.e., a Heavy Duty POV is covered for a beneficiary weighing 285 - 450 pounds; a Very 
Heavy Duty POV is covered for a beneficiary weighing 428 - 600 pounds." Your weight does not meet 
Medicare criteria for a heavy-duty power wheelchair. 
 
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 group 2 heavy-duty 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for delivery fees for oxygen equipment (A9901) provided on 
July 12, 2022. 
 
You asked the Plan to pay for the delivery fees for oxygen equipment. You say that these costs should be 
covered. The Plan denied your request. The Plan says separate payment is not made for delivery fees. 
 
The Plan must follow Medicare rules. Medicare rules say that delivery and service are an integral part of 
oxygen and durable medical equipment (DME) suppliers' costs of doing business. Such costs are ordinarily 
assumed to have been taken into account by suppliers (along with all other overhead expenses) in setting the 
prices they charge for covered items and services. As such, these costs have already been accounted for in the 
calculation of the fee schedules. 
 
We looked at the file and Medicare rules. Separate payment is not made for delivery fees. Based on this 
information, we decided that Medicare rules for coverage of the delivery fees for oxygen equipment have not 
been met. Therefore, we decided that the Plan does not have to pay for delivery fees for oxygen equipment 
(A9901) provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory panel of more than five pathogens (87631, 
87798, 87486 and 87581) provided on February 26, 2022. 
 
You asked the Plan to pay for a respiratory panel of more than five pathogens. You say that this testing was 
necessary and should be paid. The Plan denied your request. The Plan says this testing was not reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with more than five respiratory pathogens 
performed in a Part B outpatient setting are considered not medically reasonable and necessary. Medicare rules 
say that items and services that are not medically necessary are not covered. 
 
 We looked at the file and Medicare rules. The panel in this case evaluated more than five respiratory pathogens 
and was provided in an outpatient setting. Based on this information, we decided that Medicare rules for 
coverage of a respiratory panel of more than five pathogens have not been met. Therefore, we decided that the 
Plan does not have to pay for a respiratory panel of more than five pathogens (87631, 87798, 87486 and 87581) 
provided on February 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service 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 February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 08, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on February 08, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care provided on July 19, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the service should be covered. The Plan denied 
your request. The Plan says that prior authorization was not obtained. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the hospital care by a contract provider. The file does not show that the plan 
provided notice that the hospital care would not be covered. Under Medicare rules, this means the hospital care 
is considered approved by the plan. Therefore, we decided that the Plan has to pay for the initial hospital care 
provided on July 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
1, 2022 to February 22, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this device is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided February 1, 2022 to February 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on April 29, 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 that the services are not medically necessary. 
 
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. The Plan states that the services from the network provider were not medically 
necessary; however, no medical records were received for review. Without medical records, a determination 
based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pay for the 
laboratory services rendered on April 29, 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: Unfavorable

 
We decided that the Plan does not have to pay for a third level of the injection provided to the enrollee on 
February 3, 2022. 
 
You asked the Plan to pay for the third level. You say that this should be paid for. The Plan denied your 
request. The Plan says the provider did not send in evidence of a unique circumstance that would necessitate a 
third level. 
 
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 pay for the third level. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that there are not any unique circumstances that would indicate three 
levels of injection. 
 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 third level have not been met. Therefore, we decided that the Plan does not 
have to pay for a third level of the injection provided to the enrollee on February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 19, 2022, billed with 
codes 81400, 81225, 81226, 81401, 81479, 81406, 81220, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 
81283, 81291, 81306, 81328, 81335, 81350, 81355, and 81381. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 19, 2022, billed with codes 81400, 81225, 81226, 81401, 81479, 81406, 81220, 81227, 81230, 81231, 
81232, 81240, 81241, 81247, 81283, 81291, 81306, 81328, 81335, 81350, 81355, and 81381.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive oral evaluation by an oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that due to some infection concerns you were told 
you have to see an oral surgeon. The Plan denied your request. The Plan says this service is not covered under 
your Plan. 
 
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. Services must be performed 
by a participating general dentist. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive oral evaluation by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional acupuncture sessions. 
 
You asked the Plan to pre-approve 2 additional acupuncture sessions. 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. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you received 12 acupuncture sessions and the Plan 
has approved an additional 8 sessions to total 20 sessions. Therefore, the benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pre-approve 2 additional acupuncture sessions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 37785 and 36471 provided on 
July 5, 2022. 
 
You asked the Plan to pay for the medical services coded 37785 and 36471. You say that you would like this 
claim reprocessed and approved for payment as, although these services do not typically require an assistant, an 
assistant was necessary. The Plan denied your request. The Plan says payment for these services is not made 
when rendered by an assistant. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 37785 and 36471. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon 
is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for the medical services coded 37785 and 36471 have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services coded 37785 and 36471 provided on July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on March 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 diabetic supplies provided on March 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide Sus 0.5mg/2. 
 
You asked the Plan to pre-approve Budesonide Sus 0.5mg/2. You say that the medication is necessary. The 
Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide Sus 0.5mg/2.  
 
Benefits for Budesonide Sus 0.5mg/2 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from 
February 11, 2022, to March 12, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for home health services have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, for all beneficiaries receiving HH services in 
2021 whose services will continue in 2022, the HHA shall submit an NOA with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. The HHA 
should submit the artificial admission date on all subsequent claims until the beneficiary is discharged and another NOA is required. 
 
We looked at the file and Medicare rules. In this case, the admission date on the claim at issue does not match 
the admission date on the submitted NOA. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services billed for dates of service from February 11, 2022, to March 12, 2022.