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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 14, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service August 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 24, 2022. 
 
You asked the Plan to pay for the physician service. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 office visit provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 10, 2022, billed with 
codes 81206, 81210, 81235, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
March 10, 2022, billed with codes 81206, 81210, 81235, and 81272.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram procedure (93010) provided on May 
31, 2022. 
 
You asked the Plan to pay for an electrocardiogram. You say that the services at issue were not related to 
hospice care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 6, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for an electrocardiogram 
procedure (93010) provided on May 31, 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 enrollee needs LTACH for ongoing 
medical management of her wound care needing daily physician oversite, 24-hour nursing care and wound care 
and needs therapy to return to a least restrictive and most independent environment possible. The Plan denied 
your request. The Plan says the enrollee will not require daily physician visits and once a day wound care is not 
complex and does not require specialty nursing services. The enrollees continued care needs include skilled 
nursing care for the enrollees wound. When the enrollee is ready to leave the hospital, the enrollee can safely 
receive this care safely in another setting, such as a Skilled Nursing Facility (SNF) or perhaps at home with 
home health services. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. Completion of treatment at the current facility is recommended.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 71046-26, 73560-26-LT and 73560-26-RT 
billed for date of service June 17, 2022. 
 
You asked the Plan to pay for procedure codes 71046-26, 73560-26-LT and 73560-26-RT. You say that the 
enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says 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. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 11, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure codes 71046-26, 73560-26-LT and 73560-26-RT have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
71046-26, 73560-26-LT and 73560-26-RT billed for date of service June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extended respiratory pathogen panel provided on March 
31, 2022. 
 
You asked the Plan to pay for the extended respiratory pathogen panel. You say that this testing was medically 
necessary and should be paid. The Plan denied your request. The Plan says the criteria for medical necessity of 
this test are not met, and this panel was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens and/or targets. Medicare rules also say that panels with more than five respiratory pathogens performed in a 
Part B outpatient setting are considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the extended respiratory pathogen panel have not been met. Specifically, this panel was unbundled 
and billed as individual components, and this panel included more than five respiratory pathogens and was 
performed in an outpatient setting. Therefore, we decided that the Plan does not have to pay for an extended 
respiratory pathogen panel provided on March 31, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Rituximab 10MG injection (CPT code J9312). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says that the enrollee has no condition approved for the drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 medication. Our physician reviewer 
found the review has determined that the documentation supports that the Rituximab is medically reasonable 
and necessary for the enrollee. The documentation supports that the Rituximab is safe and effective for the 
enrollee. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Rituximab 10MG injection (CPT code J9312).  
 
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 an addition to lower limb prosthesis, multiaxial ankle 
with swing phase active dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system or 
equal (L5981). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested items are necessary for the enrollee. 
The Plan denied your request. The Plan says records do not support functional status is K3 ambulator. The 
enrollee's physician does not state that the enrollee is expected to be a K3 ambulator. The enrollee uses a 
wheelchair and a walker. This is not consistent with a K3 ambulator. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation provided does not support the use of the requested transtibial prosthesis with 
K3 components. There is insufficient documentation regarding the date and condition of the enrollee's current 
prosthesis and why it requires replacement. There is insufficient clinical documentation regarding the enrollee's 
current level of mobility and function and why she requires a prosthesis with K3 components when she is noted 
to use a walker and wheelchair for assistance with mobility. Additionally, there is insufficient documentation 
regarding the enrollee's motor strength and range of motion in the lower extremities. This information is needed 
to determine if the requested prosthesis is appropriate and necessary. Therefore, the requested replacement 
transtibial prosthesis with K3 components is not medically 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 prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968) and an all-lower extremity prosthesis, flex-walk system or equal (L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition solution provided from April 21, 
2022, to April 27, 2022. 
 
You asked the Plan to pay for the parenteral nutrition solution. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the submitted medical records are missing required 
documentation. 
 
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. Review of the file 
shows that the submitted medical records do not include an enrollee receipt or proof of delivery for the billed 
dates of service. 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 parenteral nutrition solution 
provided from April 21, 2022, to April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of an incompetent vein. 
 
You asked the Plan to pre-approve endovenous ablation therapy of an incompetent vein. 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 in contrast to ERFA and laser procedures, intra-
operative ultrasound guidance techniques have not been shown to increase the effectiveness or safety of 
sclerotherapy for varicose veins, therefore, intra-operative ultrasound guidance will not be separately covered 
for sclerotherapy. 
 
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 endovenous ablation therapy of an 
incompetent vein. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the Plan has already approved sclerotherapy of right lower extremity tributaries. This has not yet been 
performed. There is documentation that the enrollee has a punched-out ulcer over the shin area from an injury 
however there is no evidence that conservative efforts to treat this has been trialed and failed. There is 
satisfactory documentation of adequate arterial perfusion to lower extremities bilaterally. This ulcer is not in 
the typical distribution for perforator veins and conservative efforts plus performance of the approved 
treatments have not yet been attempted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy of an incompetent vein have not been met. 
Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy of an 
incompetent vein.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1851) and addition to lower extremity 
orthosis, suspension sleeve (L2397) provided August 19, 2022. 
 
You asked the Plan to pay for the orthoses. You say that the records show that the enrollee was seen for face-
to-face exam by their primary care physician and the reason for the exam was constant acute knee pain. The 
Medicare knee brace LCD was met, and the claim should have been paid. The Plan denied your request. The 
Plan says the records do not support the need or justification for the brace. 
 
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 physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the providers office 
indicated and verified that the enrollee was not seen by this provider on date of July 20, 2022 indicated. 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 knee orthosis (L1851) and addition to lower 
extremity orthosis, suspension sleeve (L2397) provided August 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT code E0667) and pneumatic compressor, segmental home model with calibrated 
gradient pressure (E0652). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee's records do not show they meet all of the requirements above. The Plan 
states that your request is not medically necessary because the enrollee does not have swelling of their chest, 
trunk, or abdomen. 
 
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 DME. Our physician reviewer 
found there is no documentation that the segmental PCD at issue in this case meets all of Medicare's LCD 
criteria for medically reasonable and necessary for the enrollee. Provided records do not document that the 
enrollee has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a 
standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a 
four-week trial of conservative treatment. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) 
and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the self-care/home management training services provided on January 
12, 2022. 
 
You asked the Plan to pay for the self-care/home management training services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says that an overpayment was made on a previously 
processed claim. 
 
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. Review of the file shows that the Plan that an overpayment was made on a 
previously processed claim. The file did not include the original claim that was paid. The file did not include 
the reasoning for the original overpayment. The case file was largely incomplete to support the decision 
determined by the Plan. Without this required documentation, the Plan did not substantiate their denial. 
Therefore, we decided that the Plan has to pay for the self-care/home management training services provided 
on January 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 20, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 76705 billed for date of service August 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 11, 2022, to August 12, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the enrollee did not have persistent low blood oxygen levels, persistent 
fever, or need for a machine to help with breathing. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee was diagnosed with COVID-19 pneumonia and was admitted on 
airborne precautions. He was not started on IV steroids, IV remdesivir, or oxygen support, and vitals were 
stable on admission. Therefore, based on the provided documentation, the patient appeared stable without a 
severe or complex condition to expect the patient would require hospital services that would likely cross 2 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from August 11, 2022, to 
August 12, 2022.