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

 
We decided that the Plan does not have to pay for procedure code S9343 billed for date of service April 7, 2022 
to May 4, 2022. 
 
You asked the Plan to pay for procedure code S9343. You say that this should be paid for. 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 S9343 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9343 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9343 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9343 billed for date of service April 7, 2022 to May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rabies vaccine provided on July 1, 2022. 
 
You asked the Plan to pay for the rabies vaccine. You say that this should be covered, but if it is not, then the 
claim should be reprocessed as enrollee responsibility. The Plan denied your request. The Plan says this is not 
covered by the Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the rabies vaccine. 
The Plan follows the same rules.  
 
Records do not show that the enrollee has been injured or directly exposed to any illness related to the rabies 
vaccine. The documentation only indicates that this was provided due to osteoporosis, which does not support 
direct exposure. Therefore, we decided that the Plan does not have to pay for the rabies vaccine provided on 
July 1, 2022.  
 
Benefits for the rabies vaccine 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response without transport provided on June 
9, 2022. 
 
You asked the Plan to pay for the ambulance response without transport. You say that you decided that you did 
not need to be evaluated at a hospital after consulting with the paramedics. You believe that this should be 
covered as you saved the Plan a great deal of money by not going to the hospital. The Plan denied your request. 
The Plan says this cannot be covered as Medicare does not cover ambulance response when no transportation is 
provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 9, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response without transport 
provided on June 9, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services billed with codes 72125, 70450, and 73030 provided 
on November 18, 2021. 
 
You asked the Plan to pay for codes 72125, 70450, and 73030. You say that the records support the procedure 
was performed by the provider. The Plan denied your request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The Medicare rule specifically states that, to be 
denied as a duplicate, the claims must match exactly. In this case, the claims have different place of service 
codes, which means they are not duplicates. Based on this information, we decided that Medicare rules for 
coverage of codes 72125, 70450, and 73030 have been met. Therefore, we decided that the Plan has to pay for 
imaging services billed with codes 72125, 70450, and 73030 provided on November 18, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose/reagent strips (A4253) provided from June 
20, 2022, through June 21, 2022. 
 
You asked the Plan to pay for the blood glucose/reagent strips. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says there is no separate 
payment for this service as 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. 
 
We looked at the file and Medicare rules. In this case, code A4253 has a Status Code of P under the 
Physician Fee Schedule which indicates there is no separate payment for this service as billed. Based on this 
information, we decided that Medicare rules for coverage of the blood glucose/reagent strips have not been 
met. Therefore, we decided that the Plan does not have to pay for the blood glucose/reagent strips (A4253) 
provided from June 20, 2022, through June 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an allograft. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says large population sufficiently powered randomized controlled trials that demonstrate 
long-term outcome advantages are needed. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Vivogen allograft is experimental. More research is needed to show safety and efficacy in 
spinal surgery. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of an allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has compression fracture of the 
thoracic spine. The Plan denied your request. The Plan says the records do not show an acute or subacute 
osteoporotic compression fracture. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of an imaging study showing that this fracture is acute and less than six 
weeks old. 
 
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 percutaneous vertebral augmentation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the power lift chair purchased on July 12, 
2022. 
 
You asked the Plan to provide reimbursement for the power lift chair. You say that you were not aware this 
item needed to be purchased from a Medicare provider. The Plan denied your request. The Plan says you 
purchased the item at a retail furniture store, and not from a Medicare-certified medical equipment supplier. 
This means no payment can be made for this item. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for the power lift chair 
purchased on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) treatment. 
 
You asked the Plan to pre-approve the requested use of SBRT. You say that this should be approved as prior 
treatments were very successful in treating the enrollee's disease. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SBRT is indicated for primary tumors and tumors 
metastatic to the lung, liver, kidney, adrenal gland, or pancreas. It is noted that metastases to other areas are not 
considered reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested use of SBRT. Our 
reviewer says that the requested use of SBRT is not considered medically necessary in this case. Our physician 
reviewer found the enrollee is a 79-year-old woman with a diagnosis of metastatic stage IV non-small cell lung 
cancer, previously treated to both lungs and for bilateral adrenal lesions with SBRT, and she responded very 
well. A recent PET scan was highly suspicious for metastatic disease in 1 retroperitoneal lymph node as well as 
a possible new lung lesion. The LCD does not support coverage for treatment of metastasis to a retroperitoneal 
lymph node.  
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 requested use of SBRT have not been met. Therefore, we decided that the 
Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) treatment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 7, 2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered to be 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 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a urine polymerase chain reaction (PCR) test detects the presence of bacteria differently. It is a 
multiplex polymerase chain reaction (PCR) test which identifies more bacteria than a traditional urine culture 
in patients with symptoms of a UTI. The review indicates that the services at issue in this case are not 
medically reasonable or necessary. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on July 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation provided on July 
30, 2022. 
 
You asked the Plan to pay for the ambulance transportation. You say that this was emergency transportation 
and is not hospice related. The Plan denied your request. The Plan says no Plan payment can be made as the 
enrollee was under a hospice election. The Original Medicare contractor must be billed. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency ambulance transportation provided on July 30, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 20, 2022, to 
April 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 20, 2022, to April 
6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (TENS) supplies 
(procedure code A4595) provided to the enrollee on June 19, 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 there is evidence of misrepresented services. 
 The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) items require 
a written order/prescription from the treating practitioner for Medicare payment as a condition of payment. 
 
There is no evidence that the provider who ordered these items was the provider who treated the enrollee. 
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 transcutaneous electrical nerve stimulation 
(TENS) supplies (procedure code A4595) provided to the enrollee on June 19, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found that the enrollee 
has multiple chronic issues and is at risk for medical decline following surgery and rehabilitation with a stage 2 
ulcer. There is evidence of verbal orders. The request for skilled nursing meets medical necessity criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve home health skilled nursing services.  
 
 
 
 
 
 
 
 
 
 
 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 the additional moderate sedation time provided on date of 
service June 30, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service June 30, 2022, billed with 
code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryoblation services of the knee. 
 
You asked the Plan to pre-approve cryoblation services of the knee. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been satisfied. 
 
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 cryoblation services of the knee. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is an 88-year-old woman with osteoarthritis of both knees. 
She has tried physical therapy. She takes Tylenol with Codeine for pain. She has had intra-articular steroid 
injection as well as viscosupplementation with hyaluronic acid. The requested procedure is considered 
experimental/investigational. Therefore, the request is deemed not 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 cryoblation services of the knee have not been met. Therefore, we decided that 
the Plan does not have to pre-approve cryoblation services of the knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 8, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87641) provided on February 10, 
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 coverage criteria has not been met. 
 
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 the lab services have been met. Only 
lab results were provided for review. No clinical records were provided. It cannot be determined from the records how the enrollee presented to the out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for lab services (87481, 87500, 87641) provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 28, 2022 to 
April 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
 
 
 
 
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 28, 2022 to April 
23, 2022.