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

 
We decided that the Plan has to pay for a patient lift provided from June 9, 2022, to August 9, 2022. 
 
You asked the Plan to pay for patient lift. You say that you are appealing with supporting documentation. The 
Plan denied your request. The Plan says that the proof of delivery was not itemized to indicate the specified 
items, and the Plan was unable to verify an established relationship with the ordering provider. 
 
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. Medicare rules state that proof of delivery is required for coverage of items. Medicare rules state that 
durable medical equipment (DME) requires a written order to be communicated to the supplier. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment for this item on the basis that the proof of delivery did 
not itemize the specific item billed on this claim, and the Plan was unable to verify an established relationship 
with the ordering physician. However, the signed proof of delivery includes a shipping reference number which 
identifies the specific item billed on this claim. Therefore, proof of delivery has been verified. Additionally, the 
records submitted include a written order for this item. Therefore, the Plan has not shown that its decision to 
deny payment for these reasons is correct or justified according to Medicare rules. Therefore, we decided that 
the Plan has to pay for a patient lift provided from June 9, 2022, to August 9, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery (93460). 
 
You asked the Plan to pre-approve a catheter placement in coronary artery. You say that the requested service 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says the request 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 catheter placement in coronary artery. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has a history of coronary artery atherosclerotic coronary artery 
disease with prior intervention. The medical record provided is insufficient to establish the medical necessity of 
the requested service 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 a catheter placement in coronary artery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a catheter placement in coronary artery (93460).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary due to 
COPD, OHS and CRF. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
after a fall and leg fracture.  There is a history of severe obesity and OSA, but no recorded history of COPD. 
There are no pulmonary function tests. ABGs were consistent with chronic mild CO2 retention. It appears this 
enrollee has OHS. There is no documentation to support a diagnosis of COPD. There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. This enrollee may benefit from BiPAP during sleep. 
BiPAP has not been tried and demonstrated to fail as an outpatient. Medicare does not cover a home ventilator 
when used as BiPAP and does not cover it in the treatment of OHS. 
 
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 (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 29, 2021, 
to January 5, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim was reported correctly and is supported as billed. The Plan denied your request. The Plan says although 
they agree the records support the billing of code J96.21, the diagnosis of sepsis, unspecified organism (A41.9) 
is not supported in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9). 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that this diagnosis is not supported in the medical record. Our physician reviewer found that 
the enrollee with chronic obstructive pulmonary disease (COPD) presented to the hospital with perforated 
diverticulitis and pneumonia and COPD exacerbation requiring oxygen support, antibiotics, and fluids. The 
hypoxia appeared to be directly related to the COPD and pneumonia and not a systemic dysregulated response 
to infection. Also, there was no other organ dysfunction noted in the documentation as the platelets, creatinine, 
and bilirubin were normal and the enrollee was alert and oriented. Therefore, the Sepsis 3 criteria is not met. 
The sepsis diagnosis code is, therefore, not supported in the provided documentation for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 29, 2021, to January 5, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 the enrollee requires intensive rehabilitation and 
daily physician management, 24-hour specialized rehab nursing, and intensive physical and occupational 
therapies to optimize mobility while strengthening to ensure a safe and sustainable discharge. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met at 
an alternate level of care. 
 
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 that the enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as a skilled nursing facility. 
  
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deep cleaning for four or more teeth in a mouth quadrant
(D4341) provided on August 30, 2021.

You asked the Plan to pay for the dental services. You say that you did not know you had to pay for the
services received. You say that you are on a fixed income and cannot pay for this. The Plan denied your
request. The Plan says your benefit for the requested item or service has already been exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. This benefit includes the
requested deep cleaning for four or more teeth in a mouth quadrant (D4341) but after the $2,000 annual
maximum allowable is exhausted, any remaining charges are your responsibility.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record
shows your benefit for the requested deep cleaning for four or more teeth in a mouth quadrant (D4341) was
exhausted on date of service October 25, 2021. You have an annual maximum allowable of $2,000, once this
has been met, you are responsible for any remaining charges. Therefore, we decided that the Plan does not have
to pay for deep cleaning for four or more teeth in a mouth quadrant (D4341) provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 13, 2022, billed with 
codes 81455, 81301, and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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 
July 13, 2022, billed with codes 81455, 81301, and 81194.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 12, 2022, billed with 
codes 81292, 81295, 81298, 81317, and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment based on the medical records. 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 
May 12, 2022, billed with codes 81292, 81295, 81298, 81317, and 81351.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (70450, 74177) billed for date of service 
August 1, 2021. 
 
You asked the Plan to pay for imaging services. You say that no payment has been received for these services. 
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 26, 2021, and April 1, 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 imaging services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (70450, 74177) billed 
for date of service August 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0836, E1002, E2361, E1028). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that a power wheelchair is not medically necessary. Our physician reviewer found the records provided 
show that the enrollee uses a walker to safely ambulate. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0836, E1002, E2361, E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of interlaminar/interspinous process 
stabilization/distraction device, lumbar; single level (22869) and an insertion of interlaminar/interspinous 
process stabilization/distraction device, lumbar; second level (22870). 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested procedure is unproven and not medically necessary 
procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found interlaminar devices are experimental and investigational. There is more 
research needed. There are not enough studies to show that the procedure is safe and effective to treat back 
pain. 
 
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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion of interlaminar/interspinous process stabilization/distraction 
device, lumbar; single level (22869) and an insertion of interlaminar/interspinous process 
stabilization/distraction device, lumbar; second level (22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an out-of-network (OON) provider. 
 
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 services are available from network providers. 
 
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 
an office visit with an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT scan of the chest. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the plan of the requested CT of 
the chest in order to sort out the most likely diagnosis is a reasonable request, and the results will impact the 
enrollee's care. Request for CT of the chest is 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 a CT scan of the chest have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of the chest.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON outpatient therapy services. You say that the requested provider 
provides services that are not available in-network. The Plan denied your request. The Plan says the requested 
services are available in-network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON outpatient therapy services. Our reviewer says that it is not medically 
necessary for the enrollee to receive the requested services out-of-network. Our physician reviewer found the 
enrollee has received in network rehabilitation, including acute inpatient rehabilitation, home health physical 
therapy and outpatient physical therapy. These services are standard of care and there is a lack of medical literature indicating that the requested out of network physical therapy program produces objectively superior 
outcomes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OON outpatient therapy services have not been met.  
 
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 OON outpatient therapy services. Therefore, we 
decided that the Plan does not have to pre-approve outpatient therapy services to be provided by an out-of-
network (OON) provider.