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

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on August 2, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided to the 
patient for use during surgery to prevent deep vein thrombosis. The Plan denied your request. The Plan says 
this device is not covered for this purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism 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 prevention 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 provided on August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code L0650 billed for date of service September 29, 2022. 
 
You asked the Plan to pay for code L0650. You say that you provided medical records to support payment. The 
Plan denied your request. The Plan says the patient had already received an item billed with this code on 
October 15, 2018.  The item in dispute in this case was provided less than five years from the previous one, so 
it was too soon for the member to get new equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, replacement equipment is not covered 
within the reasonable useful lifetime of the item, which can be no less than 5 years.  In this case, the patient 
received this same item less than 4 years prior to the date of service in question, so they were not eligible for a 
replacement.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code L0650 have not been met. Therefore, we decided that the Plan does not have to pay for code 
L0650 billed for date of service September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the face mask interface received on July 7, 2022. 
 
You asked the Plan to pay for the face mask interface. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the claim was processed per your plan benefits. 
 
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 states that the claim was processed per 
your Plan benefits. The Plan did not include a copy of the corrected claim for review. The documentation did 
not include any Medicare rules to support their denial. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the face mask interface received on July 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of a root canal obstruction (D3331) and 
retreatment of previous root canal therapy (D3348). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot cover the cost for these 
services. Your tooth is damaged, and you are in pain. The Plan denied your request. The Plan says these 
services are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
treatment of a root canal obstruction (D3331) and retreatment of previous root canal therapy (D3348).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standing frame/table system, one position (E0638) 
provided February 10, 2022. 
 
You asked the Plan to pay for a standing frame/table system. You say that you are confined to a wheelchair 
which requires you to use this stand assist device to get up off your wheelchair and into your bed. Without the 
stand assist, your daughter will be unable to move you from your wheelchair to your bed. The Plan denied your 
request. The Plan says standing tables are not covered, since they are a convenience item; not primarily 
medical in nature. 
 
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 pay for a standing frame/table system, one position (E0638) provided 
February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist care. You say that this provider is highly recommended. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and you can be treated within 
the Plan 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 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 
oncology care to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
71046. 
 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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service October 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (procedure codes 99232, 99233, 99239) 
provided to the enrollee from May 24, 2022, to May 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services are not supported without the required documentation. 
 
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 the denied codes is: 
 
CPT 99232: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using total time on the date of the encounter for code selection, 35 minutes must be met or 
exceeded 
 CPT 99233: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded 
 
CPT 99239: 
 
Hospital inpatient or observation discharge day management; more than 30 minutes on the date of the 
encounter 
 
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 services at issue in 
this case were not supported. Our reviewer found there are no medical records available for these dates of 
service. The documentation is only for May 21 and May 22. It cannot be verified that the procedures in 
question were performed as billed. 
 
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 hospital services (procedure codes 99232, 99233, 99239) provided to the enrollee from May 24, 
2022, to May 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for placement of a breast localization device (19283) provided 
on April 26, 2022. 
 
You asked the Plan to pay for placement of a breast localization device. You say that the service at issue has 
been billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of a device-dependent procedure 
also requires that a device be submitted on the same claim/day. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of placement of a breast localization device have not been met. Specifically, procedure code 19283 
describes a device-intensive procedure. The claim has been submitted without a code for a device. Therefore, 
we decided that the Plan does not have to pay for placement of a breast localization device (19283) provided on 
April 26, 2022.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the requested SNF care through February 20, 2023. We decided 
that the Plan does not have to pre-approve the requested SNF care after February 20, 2023.  
 
You asked the Plan to pre-approve SNF care. You say that the enrollee fell and needs more physical therapy 
before she can go home. The Plan says that the enrollee no longer meets the criteria for SNF care. 
 
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 decided that the Plan has to pre-approve the requested SNF care through February 20, 2023.  
 
Our physician reviewer found that the request for a continued stay in a SNF is medically appropriate through 
February 20, 2023. The documentation notes that the last covered date was February 17, 2023. However, on 
February 17, 2023, the nursing notes indicate the enrollee had increased shortness of breath, has 2-3+ lower 
extremity edema, and needed to start taking Lasix daily for 2 days, with a check of bloodwork on February 20, 
2023. On February 20, 2023, the physician was notified of laboratory results and instructions were to take 
additional fluids every 8 hours. It appears that daily skilled nursing was required through February 20, 2023, to 
monitor the enrollees response to Lasix. There was training given to the enrollee and their caregiver on 
February 17, 2023.  It was appropriate to continue the SNF stay through February 20, 2023. Therefore, we 
decided that the Plan has to pre-approve the requested SNF care through February 20, 2023.  
 
We also decided that the Plan does not have to pre-approve the requested SNF care after February 20, 
2023. 
 
Our physician review found that functionally the enrollee did not require ongoing skilled therapy beyond 
February 20, 2023. Therefore, we decided that the Plan does not have to pre-approve the requested SNF care 
after February 20, 2023. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on August 26, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that this admission has been correctly denied. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record did show that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on August 26, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for moderate sedation services (procedure code 99152) provided to the 
enrollee on July 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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 99152 is "Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence 
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older." 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that in this case, according to the Sedation 
Record (page 43/393), moderate sedation appears to have been administered an independent trained observer 
(additional registered nurse, per record). The sedation record documents intra-operative/intra-procedural 
monitoring of this patient (including blood pressure, heart rate, respiratory rate, electrocardiogram, oxygen 
saturation) and medications administered. The review has determined that the use of CPT 99152 is supported 
by the records provided. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
moderate sedation services (procedure code 99152) provided to the enrollee on July 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the 
enrollee on December 2, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says  the provider has billed for mutually exclusives codes for the same day of service, and that code 
G0483 is not supported by the medical record submitted. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code 
G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of procedure code G0483. This was an encounter for lab testing, nd the medical documentation 
requirements do not support the use of this procedure code. 
 
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 drug testing services (procedure code G0483) provided to the enrollee on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve dialysis. You say that this provider is closer to your home and you do not 
have anyone to drive you. The Plan denied your request. The Plan says this provider is out-of-network with the 
Plan and you can be treated within the Plan 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 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 
dialysis to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the dentures you have do not fit. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 25, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120).