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

 
We decided that the Plan does not have to pay for the pneumatic compression device billed with code E0675 
for dates of service April 28, 2022, to May 27, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided to the 
patient following shoulder surgery for the treatment of post-operative lymphedema. You said that there is 
sufficient peer-reviewed data showing the health benefits of this compression device. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675 
is only used for the treatment of peripheral artery disease. Claims for E0675 will be denied as not reasonable 
and necessary.  You billed the item in dispute with code E0675, which is not a covered code, regardless of the 
appropriateness of the device. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device billed with code E0675 for dates of service April 28, 2022, 
to May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for hospital services provided on June 8, 2022, through June 23, 2022. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that  
 
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. Specifically, the Plan has not forwarded any evidence to support their decision. 
The documentation submitted does not include a claim or initial denial to indicate how the services were billed, 
why they were denied or when they were denied. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for hospital services provided on June 8, 2022, through June 23, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Monovisc (J7327). 
 
You asked the Plan to pre-approve Monovisc. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Monovisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has been treated with medical therapy and a 2-month course of physical therapy. A review of the 
current medical literature indicates that the requested drug is considered to be reasonable and necessary after 
trial and failure or contraindication of at least 3 months of conservative therapy and failure of or 
contraindication to intra-articular glucocorticoid injections. Due to the enrollee's diagnosis of avascular 
necrosis, corticosteroid injections are contraindicated. However, there is no documentation provided indicating 
that the enrollee has tried and failed 3 or more months of physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Monovisc (J7327).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a Freesyle Libre CGM. You say that the enrollee needs this device. The 
Plan denied your request. The Plan says this item is not covered when the enrollee is not on insulin. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a Freesyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 continuous glucose 
monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87150, 
87798, 87481, 87801) provided on December 6, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this claim should be covered. The Plan denied 
your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel (87150, 87798, 87481, 87801) provided on December 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 26, 2022, to 
April 20, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA. 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 March 26, 2022. The NOA was not received by the Plan until May 2, 2022. 
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 home health services provided from 
March 26, 2022, to April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99222 and 99238 billed for April 29, 2022, 
to May 6, 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 procedure codes 99222 and 99238 are 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 99222 is initial 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, 55 minutes must be met or exceeded. The definition of code 99238 is hospital 
inpatient or observation discharge day management; 30 minutes or less 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 these services. Our reviewer says that procedure codes 99222 
and 99238 are not supported. Our reviewer found the records do not support that there was a comprehensive 
history or a comprehensive examination. The records do not support medical decision making of moderate 
complexity. Code 99222 is therefore not supported. 
 
The records are dated for May 7, 2023 but the date of discharge was May 6, 2023; therefore, code 99283 is not 
supported for May 6, 2023. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99222 and 99238 billed for April 29, 2022, to May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital outpatient clinic visit for assessment and 
management of a patient (G0463) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient. You say that due to your condition, your primary care 
physician referred you to this provider. You say that you are in a great deal of pain. You also say that you need 
an appointment sooner than the one that you have. The Plan denied your request. The Plan says there are in-
network providers available. 
 
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 
a hospital outpatient clinic visit for assessment and management of a patient (G0463) to be provided by an out-
of-network (OON) provider.
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. The Plan denied your request. The Plan says the 
enrollee's records do not show that your doctors expect that you will get better with LTACH care and hospice, 
or comfort care is not more appropriate or preferred and are being followed by palliative care. When ready to 
leave the hospital, services can safely be received in another setting, at a Skilled Nursing Facility, or at home 
with home health services or outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 8, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99223) provided on July 19, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the code 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 99223 is evaluation and management requiring a 
medically appropriate history and/or examination and medical decision making of high complexity. 
 
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 hospital care. Our reviewer says that the records do not 
support the code billed. Our reviewer found the documentation does not describe medical decision-making of 
high complexity as required for this code. The patient was stable, tolerated the uncomplicated procedure, and recovered as expected without serious comorbidities. 
 
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 hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital care (99223) provided on July 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 29, 2022, to August 
27, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. 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 30, 2022. The NOA was not received by the Plan until December 
23, 2022. 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 home health services provided 
from July 29, 2022, to August 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on November 
28, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
November 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for November 16, 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 procedure code 99285 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 these services. Our reviewer says that procedure code 99285 is not supported. Our reviewer found the records show that a comprehensive examination was taken but there is 
no documentation of a comprehensive history or medical decision making of high complexity. Code 99285 is 
therefore not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99285 billed for November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
rental billed for date of service December 3, 2022. 
 
You asked the Plan to pay for the CPAP device rental. You say that the enrollee has begun using the CPAP 
device again, and this claim should be paid. The Plan denied your request. The Plan says it is not clear why 
rental for the prior CPAP device is being requested as it was received several years ago. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 CPAP device rental have been met. 
It is not clear from the records provided that a rental payment would be due for the CPAP device at issue. It is 
noted that the enrollee received the CPAP in 2019 but was not using it for some period of time. Though the 
records show that CPAP supplies were delivered, it is not clear that additional rental payments are due for a 
CPAP that was delivered more than 13 months prior to the date of service. Rental payments would generally 
only begin again if a new device were provided. Therefore, we decided that the Plan does not have to pay for 
the continuous positive airway pressure (CPAP) device rental billed for date of service December 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for care in 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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) of 8-14 drug classes 
(G0481) provided on June 23, 2022. 
 
You asked the Plan to pay for definitive UDT of 8-14 drug classes. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says more than 8-14 classes of drugs were tested. 
 
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 G0481 is the definitive UDT of 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records show that more 
than 14 classes of drugs were tested. Based on this information, we decided that Medicare rules for coverage of definitive UDT of 8-14 drug classes have not been met. Therefore, we decided that the Plan does not have to 
pay for definitive urine drug testing (UDT) of 8-14 drug classes (G0481) provided on June 23, 2022.