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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement that indicates these tests are included in the dialysis rate. The Plan denied your request. 
The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 8, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 21, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 July 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 9, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this was not a bundled charge. 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 June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request is not medically necessary, the services the enrollee needs can 
be provided safely in other settings, for example, a skilled nursing facility. 
 
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 the intensity of services provided at an IRF.  
 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 93970 billed for date of service October 
13, 2020. 
 You asked the Plan to pay for procedure code(s) 93970. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 93970. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 93970. Based on this information, 
we decided that Medicare rules for coverage of procedure code 93970 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 93970 billed for date of service October 13, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Micro-Invasive Glaucoma Surgery (MIGS). 
 
You asked the Plan to pre-approve MIGS. 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 glaucoma surgical aqueous drainage devices will be 
considered medically reasonable and necessary when approved by the FDA and used within accordance of the 
FDA-approved/cleared indications. 
 
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 MIGS. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not meet the coverage 
criteria detailed in the LCD. The documentation does not support that the enrollee was using glaucoma/ocular 
hypotensive eye drops prior to the proposed cataract extraction with micro-invasive glaucoma 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 MIGS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Micro-Invasive Glaucoma Surgery (MIGS).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enoxaparin sodium. 
 
You asked the Plan to pre-approve Enoxaparin sodium. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Enoxaparin sodium.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the Dexcom G6 will give you a more accurate 
reading. The Plan denied your request. The Plan says you do not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 CGM have been met. The plan 
attempted to get medical records but none were submitted, without them we cant determine whether you meet 
Medicare criteria for a CGM. Supporting medical records should be sent to the Plan to show why you need a 
CGM. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the post-Vitrectomy support durable medical 
equipment (DME) (E1399) provided from July 18, 2022, to July 25, 2022. 
 
You asked the Plan to reimburse you for the DME. You say that you rented this DME to aid you in enduring 
the difficult recovery from your surgery. You say that this equipment is no different than a walker or 
wheelchair to those who need aid with mobility following surgery. You also say that you feel this should be 
covered. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to reimburse you for the post-Vitrectomy support durable medical 
equipment (DME) (E1399) provided from July 18, 2022, to July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75625 and 36245 billed for date of service 
May 13, 2022. 
 
You asked the Plan to pay for procedure codes 75625 and 36245. The Plan denied your request. The Plan says 
payment for codes 75625 and 36245 is bundled into payment for code 36252. 
 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 codes 
75625 and 36245 are column II codes to column I code 36252. 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 codes 75625 
and 36245 billed for date of service May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on September 19, 
2022, billed with codes 71046 and G0463. 
 You asked the Plan to pay for the outpatient hospital services as billed. You say that this claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says OCE edit 21 must be corrected for 
this claim to be processed. 
 
The Plan must follow Medicare rules. Medicare rules say that all outpatient hospital claims must be processed 
through the IOCE. OCE edit 21 is invoked when an EM code without modifier -25 is billed on the same date of 
service as a type T or S code.  
 
We looked at the file and Medicare rules. Code G0463 is an EM code which was billed along with code 71046 
which has an OPPS status indicator of S. Modifier -25 was not appended to the EM code as required. Based on 
this information, we decided that Medicare rules for coverage of the outpatient hospital services as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services 
provided on September 19, 2022, billed with codes 71046 and G0463.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (83036) provided on May 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 83036 is "Hemoglobin; glycosylated (A1C)". 
 
We asked our coder 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 use of code 83036 is 
not supported by the records provided. Our reviewer found that medical records do not support the use of code 
83036 as there is no result for the A1C. 
 
We looked at this coder'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 the services (83036) provided on May 9, 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 receive around the clock care and prevent deterioration. The Plan denied your request. The Plan 
says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The requested service cannot be 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70546 billed for date of service September 
18, 2022. 
 
You asked the Plan to pay for procedure code 70546. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70546 is bundled into payment for code 
70553. 
 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 70546 
is a column II code to column I code 70553. 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 70546 billed for date of service September 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99387 billed for date of service January 13, 
2022. 
 
You asked the Plan to pay for procedure code 99387. The Plan denied your request. The Plan says procedure 
code 99387 is non-covered 
 
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 99387 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 99387 is not covered. Based on this information, we decided that Medicare rules for coverage of procedure code 99387 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99387 billed for date of service January 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 You asked the Plan to pre-approve the portable oxygen concentrator. You say that the enrollee needs the 
portable concentrator. The enrollee is unable to move the current oxygen tank and you want to switch to the 
portable. The Plan denied your request. The Plan says there is no indication the enrollee's current oxygen 
equipment is not meeting their medical needs or activities of daily living in or around the home. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable oxygen concentrator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records document hypoxemia on room air to meet Medicare 
criteria for home oxygen therapy. The enrollee meets criteria for supplemental oxygen. The provided records 
document the portable oxygen concentrator is requested to be able to exercise, run errands or function day to 
day. The Provided records do not document that the portable oxygen concentrator is required to meet the 
enrollee's medical needs for activities of daily living in the home and that the current oxygen equipment is not 
meeting these needs. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of 12 
additional PT visits. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Based on the records the enrollee appears to have improved with therapy to the point of meeting a 
majority percentage of most of their long-term goals. After 69 PT treatments, further utilization of the home 
exercise program appears appropriate at this point. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional PT visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manipulation of the ankle under general anesthesia. 
 
You asked the Plan to pre-approve manipulation of the ankle under general anesthesia. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 manipulation of the ankle under general 
anesthesia. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
manipulation of the ankle under general anesthesia, in this case, is 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 manipulation of the ankle under general anesthesia have not been met. 
Therefore, we decided that the Plan does not have to pre-approve manipulation of the ankle under general 
anesthesia.