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

 
We decided that the Plan has to pay for the infusion supplies not used with an external infusion pump (A4223) 
provided from July 5, 2022, to July 12, 2022. 
 
You asked the Plan to pay for the infusion supplies. You say that your department requires reimbursement for 
the underpaid charges. The Plan denied your request. The Plan says that this service is not covered by 
Medicare. 
 
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 records do not support that the supplies in dispute were used 
with a disposable drug delivery system. This means that the Plan has not provided a valid reason for denying 
payment of the infusion supplies not used with external infusion pump. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for the infusion supplies not used with an external 
infusion pump (A4223) provided from July 5, 2022, to July 12, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the medical eye exam (92014) provided on September 14, 2022. 
 
You asked the Plan to pay for the medical eye exam. You say that previous visits with physicians from this 
clinic have always been in-network. You also say that your annual eye exams have always been covered in the 
past, and you would like to know why this exam is not covered. The Plan denied your request. The Plan says 
that this claim processed correctly due to the fact that the approved vision department does not have a claim on 
file for September 14, 2022. 
 
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 records do not support the Plan's denial of payment for this case. This means 
that the Plan has not provided a valid reason for denying payment of the medical eye exam. It is the burden of 
the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so 
we must find in your favor. Therefore, we decided that the Plan has to pay for the medical eye exam (92014) 
provided on September 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT) guidance for placement of radiation 
therapy fields (77014) provided on March 14, 2022. 
 
You asked the Plan to pay for the CT guidance. The Plan denied your request. The Plan says that this charge is 
incidental to another service. 
 
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 records do not support that the CT guidance (77014) was done as part of the 
intensity modulated treatment delivery (G6015), and there are no active National Correct Coding Initiative 
(NCCI) edits between the two codes. This means that the Plan has not provided a valid reason for denying 
payment of the CT guidance for placement of radiation therapy fields. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for the computed tomography (CT) guidance for 
placement of radiation therapy fields (77014) provided on March 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
October 15, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that this claim was billed in 
accordance with the enrollee's insurance policy allowable, accepted procedure codes, and diagnosis codes 
according to plan type. The Plan denied your request. The Plan says the Proof of Delivery did not include an 
order number or details to corroborate the Delivery Ticket submitted. The Plan also says the Proof of Delivery 
is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. 
 The Plan must follow Medicare rules. Medicare rules say that if the supplier does not have appropriate proof of 
delivery documentation within the prescribed timeframes, associated claims will be denied and overpayments 
recouped. 
 
We looked at the file and Medicare rules. Specifically, no Proof of Delivery was supplied for the supplies at 
issue in this case. The Proof of Delivery that has been provided is for the device itself. Based on this 
information, we decided that Medicare rules for coverage of the electrical stimulator supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) 
provided on October 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you need this bed for more 
support. The Plan denied your request. The Plan says the total electric hospital bed you are requesting does not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that total electric beds will be denied as 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 total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed (E0265).
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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an LTACH care. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative electromyography monitoring services 
(codes 95927, 95937, 95938, and 95939) provided on April 5, 2022. 
 
You asked the Plan to pay for the intraoperative electromyography monitoring services. You say that the 
medical necessity for the services performed is clearly supported. The Plan denied your request. The Plan says 
charges for or in connection with services or supplies that are, as determined by the Plan, considered to be 
experimental or investigational are excluded from coverage under the enrollee's plan. 
 
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 intraoperative electromyography 
monitoring services. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found given the conflicting evidence to date and 
the overarching consensus that further study is necessary to evaluate the use of intraoperative 
neurophysiological monitoring (IONM) in lumbar spine surgery, the requested service is not supported as 
medically necessary. Our reviewer found that the records did not support that code 95937 was done in a 
manner consistent with the applicable LCD. Rather, the services were not provided to evaluate a disorder of the 
neuromuscular junction (NMJ). Our physician reviewer also found that the enrollee was not suspected of 
having a problem involving the NMJ either. In as much, medical necessity cannot be established at this time. 
 
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 intraoperative electromyography monitoring services have not been met. 
Therefore, we decided that the Plan does not have to pay for the intraoperative electromyography monitoring 
services (codes 95927, 95937, 95938, and 95939) provided on April 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to gain mobility with the goal of returning home. The Plan denied your request. The Plan says the 
member is receiving appropriate inpatient acute care and does not require transfer to a long term acute care 
hospital (LTACH). 
 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage. 
 
You asked the Plan to pre-approve additional transportation mileage. You say that all the in-network providers 
are not close to your home. The Plan denied your request. The Plan says the service is a covered benefit, but 
you have exceeded the limits set in the subscriber agreement. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the trip does not exceed 50 miles. 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional transportation mileage.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the enrollee 
to receive the care needed. The Plan denied your request. The Plan says the records do not support the need for 
daily therapy on an inpatient basis. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
October 26, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that it is impossible for the enrollee to 
initiate and continue treatment without the prescribed supplies. The Plan denied your request. The Plan says 
code A4595 remains not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, an 
order number was not provided for this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
electrical stimulator supplies (A4595) provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), deluxe frames (V2025), and single 
vision lenses (V2100) purchased on September 30, 2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames, deluxe frames, and single vision lenses. You say that your claim for 
reimbursement was denied with the reason, "missing lens type". You also say that you are not sure where you 
need to send the corrected claim to, and that you will send copies to both in hopes of being reimbursed. The 
Plan denied your request. The Plan says you received this eyewear from a provider who is outside of the Plans 
network of providers. The Plan also says that there are contracted providers within your service area. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use a doctor in the Plan's vision network. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received this eyewear from a 
provider who is not in the Plan's network. Based on this information, we decided that the Plan's rules for 
coverage of the frames, deluxe frames, and single vision lenses have not been met. Therefore, we decided that 
the Plan does not have to pay for the frames (V2020), deluxe frames (V2025), and single vision lenses (V2100) 
purchased on September 30, 2022, from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided on August 15, 2022. 
 
You asked the Plan to pay for the TENS device. You say that this claim was billed in accordance with the 
enrollee's insurance policy allowable, accepted procedure codes, and diagnosis codes according to plan type. 
The Plan denied your request. The Plan says the documentation submitted did not include a Proof of Delivery, 
or a Delivery Ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery provided in this case. Specifically, there is a delivery 
ticket and proof of delivery that were provided with this case. However, both of these documents support a date 
of service of July 15, 2022, and not the billed date of service of August 15, 2022. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) device (E0730) 
provided on August 15, 2022.
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 enrollee continues to require intensive, active, 
ongoing acute access medically and functionally. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 for ultrasound guidance for vascular 
access, and moderate sedation services billed with code 99153 billed for date of service August 12, 2022. 
 
You asked the Plan to pay for procedure codes 76937 and 99153. You say that you would like payment to be 
reconsidered for this claim. The Plan denied your request. The Plan says payment for code 76937 is bundled 
into payment for code 36475. The Plan also says that code 99153 is not payable in the facility setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules also 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.  
 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76937 
is a column II code to column I code 36475 with a modifier indicator of 0. The column II code is therefore not 
payable. We also 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. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 76937 for ultrasound guidance for vascular access, and moderate sedation services 
billed with code 99153 billed for date of service August 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
September 20, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says code A4595 remains not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, an 
order number is not included for this case. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
electrical stimulator supplies (A4595) provided on September 20, 2022.