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

 
We decided that the Plan does not have to pay for lab services provided on July 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing services provided on September 10, 2022. 
 
You asked the Plan to pay for the panel testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says there was insufficient information provided to approve this request. 
 
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, there are insufficient medical records from the treating 
physician to show the testing was ordered for a covered clinical indication. We find that the testing was not 
billed with a single code as required. Based on this information, we decided that Medicare rules for coverage of 
the panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the panel 
testing services provided on September 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (E0483). 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation device. You say that this device is 
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 high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device (E0483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided September 1, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended lifetime use of equipment as they are 
diagnosed with chronic pain and compromised mobility without the option for surgical correction. The Plan 
denied your request. The Plan says the information submitted does not support this level of service. 
 
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, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the enrollee and verified 
that no electrical stimulator supplies was received. 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, 2 lead, per month, (e.g., TENS, NMES) (A4595) provided September 1, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder Detect (0013M) provided on June 7, 2022. 
 
You asked the Plan to pay for the CXbladder Detect. You say that is testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder Detect have not been met. Therefore, we decided 
that the Plan does not have to pay for the CXbladder Detect (0013M) provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided August 10, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the equipment was prescribed by 
the doctor and was issued to the enrollee for use during their surgery. The Plan denied your request. The Plan 
says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
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) and segmental pneumatic appliances (E0673) provided 
August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 and half leg appliance for August 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) billed with code E0675 and half leg appliance for August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99496 billed for September 15, 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 procedure code 99496 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99496 is transitional Care Management Services with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of high complexity during the service 
period Face-to-face visit, within 7 calendar days of discharge. 
 
We find that CPT code 99496 is not supported in the medical record. Specifically, there are no medical records 
to support that the billed services were performed for the date of service at issue. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99496 billed for September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says there is an in-network provider that can perform the 
services the enrollee needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 97535 billed for date of service January 8, 2022. 
 
You asked the Plan to pay for procedure code 97535. You say that this service was separate and distinct and 
should be paid. The Plan denied your request. The Plan says that the payment for this service is included in the 
payment for another service provided on this date. 
 
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 does not clarify in their denial which service provided 
includes code 97535. No documentation or claims were provided to show that this code was billed with any 
other service on the date in question. There is an explanation of benefits which shows one other service may 
have been provided to this enrollee on this date; however, the procedure code of this service is not noted or 
provided. The Plan's denial is not substantiated in this case as we cannot verify that any other services were 
provided which would include the payment for the service at issue. Therefore, we decided that the Plan has to 
pay for procedure code 97535 billed for date of service January 8, 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 pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you use these supplies daily. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a durable medical equipment (DME) purchase under 
special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that DME may be purchased only during the 10th 
continuous month of rental. The contract with the Plan offers special supplemental benefits for the chronically 
ill (SSBCI) when specific criteria are met. 
 
We looked at the file and the Plan's rules. There is no documentation that the enrollee meets all of the Plan's 
criteria for the SSBCI benefit. Based on this information, we decided that the Plan's rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a durable medical 
equipment (DME) purchase under special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on May 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for anesthesia services is made to the 
physician who personally performed the entire anesthesia service alone or a qualified nonphysician anesthetist. 
 
We looked at the file and Medicare rules. The file shows that the anesthesia services were not performed by a 
physician or qualified nonphysician anesthetist. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services rendered on May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gel arm rests and a specialty seat cushion (K0108 x2) 
for a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says these items are deluxe items that are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair seat and back cushion codes are all-
inclusive. Use of code K0108 or any other code to separately bill for added components such as the foam 
blocks, gel packs, air cells, or equivalent material is incorrect coding. 
 
We looked at the file and Medicare rules. Code K0108 is being used for gel arm and seat cushions. This is 
incorrect coding. These items are upgrade features. Based on this information, we decided that Medicare rules 
for coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve gel arm rests and a specialty seat cushion (K0108 x2) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical foods for inborn errors of metabolism (S9435). 
 
You asked the Plan to pre-approve medical foods. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not a covered service under 
Medicare or the Plan. In addition, the 2023 National Physician Fee Schedule lists code S9435 with a status 
indicator of 1, indicating that this CPT code is not valid 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 S9435 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9435 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of medical foods have not been met. Therefore, we decided that the Plan does not have to 
pre-approve medical foods for inborn errors of metabolism (S9435).
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 a 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 a home ventilator. Our physician reviewer found the enrollee has a 
diagnosis of chronic obstructive pulmonary disease (COPD) and has been hospitalized twice in the last few 
months.  During the most recent hospitalization, in January 2023, an arterial blood gas (ABG) test showed a 
normal PaCO2 and pH.  There is no ABG, done while stable, documenting chronic CO2 retention. Therefore, the enrollee does not meet criteria for nocturnal ventilatory support. If the enrollee did have chronic CO2 
retention, could benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device. 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that the requested Barostim Neo device is 
medically necessary. The Plan denied your request. The Plan says the requested Barostim Neo device is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 Barostim Neo device. Our reviewer 
says that the requested Barostim Neo device is not medically necessary. Our physician reviewer found 
Baroreflex stimulation devices have been considered potential alternative treatments for resistant hypertension 
and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath the clavicle 
with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers electrical 
impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In August 2019, 
the Food and Drug Administration (FDA) approved the system for use in patients with refractory heart failure 
who remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have 
an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved 
cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees 
clinical management. 
 
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 Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM system. You say that the enrollee has obsessive 
compulsive personality disorder and poking his fingers triggers symptoms such as anxiety. The enrollee needs 
the requested CGM system. The Plan denied your request. The Plan says the enrollee is not on insulin and 
therefore, does not meet approval for the requested CGM system. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin, 
insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre CGM system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are medically necessary. 
The Plan denied your request. The Plan says these items are not eligible for Medicare coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 and half leg appliance for August 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) billed with code E0675 and half leg appliance for August 19, 2022.