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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to perform activities of daily 
living, and home care is not sufficient at this time. The Plan denied your request. The Plan says the SNF 
services you are requesting do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
however, provided records do not document that the enrollee has the tolerance for regular daily skilled therapy 
services. The enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. Records support that services in a long-term care facility on a part time basis are 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crutch substitute, lower leg platform, with or without 
wheels (E0118) purchased July 12, 2022. 
 
You asked the Plan to pay for a crutch substitute. You say that you needed the crutch because you were not 
allowed to bear any weight on your leg. The Plan denied your request. The Plan says there is insufficient 
published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the 
medical necessity for a knee scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a crutch substitute have not been met. Therefore, we decided that the Plan does not have to pay for 
a crutch substitute, lower leg platform, with or without wheels (E0118) purchased July 12, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (64484, 64483). 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, although 
the enrollee has continued low back pain with radicular symptoms and had great benefit from prior 
transforaminal epidural steroid injection (TFESI), there were no provided documentation of number of 
injections the patient had prior to the most recent request. The review has determined that the enrollee does not 
meets the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (64484, 64483).
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 28, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. 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 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 (82962). 
 
You asked the Plan to pre-approve a Dexcom G6. 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 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 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G6 (82962).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0480, 80307) provided on March 23, 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 (G0480, 80307) provided on March 23, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre. 
 
You asked the Plan to pre-approve a Freestyle Libre. 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 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 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99203 for August 1, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that Medicare may not pay for an evaluation and 
management service billed with the CPT modifier -57 if it was provided on the day of or the day before a 
procedure with a 0 or 10-day global surgical period.  
 
We looked at the file and Medicare rules. The file shows that procedure code 99203 was billed with the -57 
modifier on the same day as minor surgical procedure 26000. Procedure code 26000 has a global surgical 
period of 0 days; therefore, the -57 modifier is not appropriate. Therefore, we decided that the Plan does not 
have to pay for the office visit billed with code 99203 for August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
 
We decided that the Plan does not have to pay for tracheostomy supplies provided on August 21, 2022, to 
September 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for DME supplies. You say that you are requesting reimbursement for DME supplies 
purchased with an on-line retailer. The Plan denied your request. The Plan says the on-line retailer has not 
agreed to accept Medicare-approved amounts as a full payment for covered services. 
 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for tracheostomy supplies provided on August 21, 
2022, to September 22, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided July 20, 2022. 
 
You asked the Plan to pay for the tens device. You say that the prescribing physician recommends an extended 
lifetime use of equipment as the enrollee is diagnosed with chronic pain and compromised mobility without the 
option for surgical correction. The Plan denied your request. The Plan says evidence of misrepresented services 
 
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 proof of delivery did not include an order 
number or details to corroborate the delivery ticket submitted. Also, the proof of delivery is not itemized to 
indicate the specific supplies. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and suspension 
sleeve (E0673), provided on June 30, 2022. 
 You asked the Plan to pay for a pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these items are not covered for preventions of venous 
thromboembolism nor for treatment of peripheral artery disease or in a ambulatory surgical center 
 
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 suspension sleeve (E0673), provided on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6197, A6211, and A6253 billed for date of 
service February 3, 2022. 
 
You asked the Plan to pay for procedure codes A6197, A6211, and A6253. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says procedure codes A6197, A6211, and A6253 are 
excluded from the fee schedule. 
 
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 A6197, A6211, and A6253 have a status indicator of P on the Physician Fee 
Schedule. This means that procedure code A6197, A6211, and A6253 are not payable. Based on this 
information, we decided that Medicare rules for coverage of procedure codes A6197, A6211, and A6253 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A6197, A6211, and 
A6253 billed for date of service February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker, wheeled, rigid or folding (E0149) 
and seat attachment (E0156). 
 
You asked the Plan to pre-approve a heavy-duty walker and seat attachment. You say that you need the walker 
because you cannot do anything at home without the assistance of a home health aide. The Plan denied your 
request. The Plan says you do not meet medical criteria for coverage of the requested walker. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries 
who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. The LCD confirms that you must weigh 300 or more pounds to meet 
criteria for approval. The records do not show that you weigh 300 pounds or more. Based on this information, 
we decided that Medicare rules for coverage of a heavy-duty walker and seat attachment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker, wheeled, rigid or 
folding (E0149) and seat attachment (E0156).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01142 provided on June 10, 
2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 01142 is anesthesia for procedures on arteries of knee 
and popliteal area; popliteal thromboendarterectomy, with or without patch graft. 
 
We find that CPT code 01142 is not supported in the medical record. Specifically, the documentation shows 
that this code was already processed and paid by the Plan for this date of service. If multiple procedures are 
performed on the same date of service, the provider should indicate separately identifiable sessions using 
appropriate modifiers. This code was not billed with an appropriate separately identifiable modifier. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01142 provided on 
June 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 5, 2022, to 
February 3, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 5, 2022. The NOA was not received by the Plan until July 9, 2021. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
January 5, 2022, to February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computerized tomography (CT) scan of the chest. 
 
You asked the Plan to pay for the CT scan. You say that the CT scan was medically necessary. The Plan denied 
your request. The Plan says the Medicare criteria were not 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 pay for the CT scan. Our reviewer says that the CT 
scan of the chest is not medically necessary. Our physician reviewer found that in this case, the record indicates 
that the enrollee underwent a CT scan of the chest following a fall. The record provided does not include 
provider notes documenting the clinical rationale for the requested test. The provided records do not indicate 
the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are not satisfied. 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a computerized tomography (CT) scan of the chest.
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 without this rehabilitation, the enrollee will not 
regain their full ability to function independently or regain full respiratory function which will be life altering. 
The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements 
for approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93460). 
 
You asked the Plan to pre-approve cardiac catheterization. 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 cardiac catheterization is covered when specific 
criteria are met. 
 
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 cardiac catheterization. Our reviewer says that the services are not medically necessary. Our physician reviewer found radionuclide stress was 
negative for ischemia. Guidelines would not support the necessity of this invasive procedure at this point. In 
summary, there is insufficient documentation to support the medical necessity of cardiac catheterization in this 
enrollee's 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93460).