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

 
We decided that the Plan does not have to pre-approve continuous airway pressure (CPAP) device (E0601). 
 
You asked the Plan to pre-approve the CPAP device. You say that you have been trying to get a CPAP machine 
for several months and cannot seem to get the equipment. You received your sleep study, and the doctor 
submitted the information, and you still continue to get denied. The Plan denied your request. The Plan says 
there is no physician order on file for this item, or documentation that the enrollee has had the required testing 
with results showing that he meets the Medicare coverage criteria for this item. 
 
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 physician order for the supplies provided in this case. Specifically, there is 
o physician order for the requested CPAP. The rules say that a CPAP is covered when very specific criteria is 
met, with results of specific tests to indicate that the coverage criteria is met. 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 pre-approve continuous airway pressure (CPAP) device (E0601).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 9, 2021, to January 7, 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 inpatient admission is not authorized as a separate admission. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital.  
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 services. Our reviewer says that the 
requested services are not supported in the medical records. Our physician reviewer found that in this case, the 
documentation indicates the member was discharged from the hospital with plans for a staged treatment and 
surgery for the same diagnosis. The inpatient admission from 12/9/21 to 1/7/22 was not medically necessary to 
be a separate admission with a separate DRG payment. The stay could have been a continuation of the initial 
admission. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services provided to the enrollee from December 9, 2021, to January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 5, 2022, to January 10, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 diagnosis code 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 the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that in this case, there was no clinical or laboratory evidence of sepsis. The review has 
determined that the records did not support the use of diagnosis code A41.9 in this case.  
 
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 to the enrollee from January 5, 2022, to January 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed wing air transportation (A0430) and fixed wing air 
mileage (A0435) provided on December 18, 2021. 
 
You asked the Plan to pay for the services. You say that the medical records support that this was an emergent 
transport. The Plan denied your request. The Plan says charges for non-emergency ambulance are not covered 
under the enrollee's plan. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that a 
non-emergent Bentall procedure along with mitral valve replacement was recommended but transfer to a 
tertiary center was initiated due to limitations of sending hospital. She was noted to have been improving and 
stable on the initial treatment regimen. She was transported via fixed wing air transportation on December 18, 
2021. The documentation does support that the patient suffers from an illness or injury that contraindicates 
transportation by any means other than ambulance. The documentation, however, does not support that the 
patient's condition was such that the time needed to transport a patient by ground, or the instability of 
transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. 
The documentation does support that the transferring hospital did not have adequate facilities to provide the 
medical services needed by the patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the fixed wing air transportation (A0430) and fixed wing air mileage (A0435) provided on 
December 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, 
E2213x2, E2363x2, E1028x4, E2377, E2313, E1007; E2311, E0955, E0953x2, K0108, E2608). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says records show the 
enrollee has a Quantum Rehab/Quantum 4 Front 3 SP-SS wheelchair which was purchased in January 2019. 
Records submitted do not show a change in the enrollees condition to support the new PWC. The records do 
not show that the current PWC is in disrepair and requires repairs. 
 The Plan must follow Medicare rules. The rules say that replacement refers to the provision of an identical or 
nearly identical item. 
 
The file shows that the enrollee purchased a power wheelchair in January 2019. This wheelchair serves the 
same purpose as the requested wheelchair. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair and accessories (K0861, E2213x2, E2363x2, E1028x4, E2377, E2313, E1007; 
E2311, E0955, E0953x2, K0108, E2608).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you disagree with the denial. The 
Plan denied your request. The Plan says Medicare does not cover repairs when the expense for repairs exceeds 
the estimated expense for replacement of the wheelchair. 
 
The Plan must follow Medicare rules. Medicare does not cover the cost of repairs if these costs exceed that of 
replacement. 
 
 
 
 
 
 We looked at the file and Medicare rules. The records show that the enrollee received the wheelchair in 
September 2018. The records also show the enrollee has received repairs to this wheelchair totaling 
$12,178.00. The replacement cost for the chair as currently configured is $9,629.65. The enrollee has exceeded 
the cost of the replacement of the wheelchair. Based on this information, we decided that Medicare rules for 
coverage of power wheelchair repairs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve power wheelchair repairs.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (epoetin alfa) injections. 
 
You asked the Plan to pre-approve the Procrit injections. You say that it is felt that this treatment is medically 
necessary. The Plan denied your request. The Plan says this is not supported for treatment of sickle cell anemia, 
and there is no myelosuppressive chemotherapy planned. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Procrit injections. Our reviewer 
says that the requested treatment is not shown to be medically reasonable and necessary. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of sickle cell anemia and a distant history 
of lung cancer with no evidence of disease, in the absence of planned myelosuppressive chemotherapy. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied.   
 
 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 Procrit injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Procrit (epoetin alfa) injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services (procedure codes 95886, 95907) 
provided to the enrollee on July 18, 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 denied codes are not supported by the medical records 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 the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95907:  
Nerve conduction studies; 1-2 studies 
 
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 in terms of CPT 95907, a nerve 
conduction study (NCS) was not done during the course of this surgical procedure. Rather, the surgeon 
performed what is called pedicle screw testing. That uses the electromyography (EMG) recording for 
measurement. There was no documentation that a formal NCS was done during the procedure. Pedicle screw 
testing, as it is considered to be triggered EMG, is included in a CPT code for EMG services. As such this 
service is not supported by the records as billed. As NCS was not performed, CPT 95886 would also not 
represent the most appropriate code for this procedure. 
 
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 neurophysiology services (procedure codes 95886, 95907) provided to the enrollee on July 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232) provided on September 1, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this provider is not eligible to receive Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for physician services (99232) provided on 
September 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 20, 2022. 
 
You asked the Plan to pay for ambulance services. You say that  The Plan denied your request. The Plan says  
 
Your appeal request for the enrollee is not valid. You can make a request for ambulance services for the 
enrollee only if you are the legal representative of the enrollees estate. Until you show that you are the legal 
representative of the enrollees estate, you cannot appeal on behalf of the estate. 
 Therefore, we decided that the Plan does not have to pay for ambulance services provided on July 20, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on January 15, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you have been enrolled in 
Medicare since December 1, 2021 and have attached the Medicare Certification letter. The Plan denied your 
request. The Plan says that Medicare does not cover services that are not performed by a Medicare-certified 
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. 
 
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 provided documentation to substantiate their 
denial. Therefore, we decided that the Plan has to pay for an emergency department visit provided on  
January 15, 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 pay for saline billed with a drug not otherwise classified (NOC) code 
J3490 provided from January 1, 2022, to January 7, 2022. 
 
You asked the Plan to pay for drug not otherwise classified code J3490. You say that this drug was a necessary 
part of the infusion therapy. The Plan denied your request. The Plan says there is a more appropriate code for 
this drug, which is J7040. 
 
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 J3490 is unclassified drug.  
We find that CPT code J3490 is not supported in the medical record. Specifically, you billed a drug not 
otherwise classified (NOC) code for saline. However, saline has been classified with code J7040, meaning code 
J3490 is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage 
of drug not otherwise classified code J3490 have not been met. Therefore, we decided that the Plan does not 
have to pay for saline billed with a drug not otherwise classified (NOC) code J3490 provided from January 1, 
2022, to January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0037U) provided on July 18, 2022 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (0037U) provided 
on July 18, 2022
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Durysta implant. 
 
You asked the Plan to pre-approve the Durysta implant. You say that there is no way of knowing whether the 
drug provided has the allergen that will cause a reaction in the enrollee. You feel that this would present a 
danger and that the best way to avoid this is to use the requested implant. The Plan denied your request. The 
Plan says it was confirmed that the drug is available without the allergen at issue. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Durysta implant. Our reviewer says 
that the requested treatment is not considered medically reasonable and necessary based on step therapy 
criteria. Our physician reviewer found the record indicates that the enrollee has open angle glaucoma. The 
requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed 
the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to 
or would have an adverse effect from the plan's preferred step one alternative. The record indicates that a 
preservative free drug that is a step one preferred agent is available. The elements of the coverage criteria are 
not satisfied.  
 
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 Durysta implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Durysta implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the seat lift is medically 
necessary. The Plan denied your request. The Plan says the power 10" lift accessory is not felt to show medical 
necessity and is only a convenience item. You are fully dependent for transfer on the assistance of a 24-hour 
caregiver with the use of a hydraulic lift system that is already provided. 
 
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 pre-approve a power seat elevation system (E2300).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you are appealing with supporting records. 
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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial preventive physical examination (G0402) provided on 
June 15, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Review of the records indicate that 
the enrollee had surgery procedure code 69210 on the date of service June 15, 2022. This provider also 
performed procedure G0402 on the same date of service June 15, 2022. Surgery procedure 69210 has a global 
surgery value of 000 on the CMS National Physician Fee Schedule (NPFS) Relative Value (RVU) File. This is 
an endoscopy or minor procedure that has a global surgery period of 0 days. The same servicing provider 
rendered the evaluation code, G0402, on the date of service June 15, 2022. The appealed G0402 was not billed 
with an appropriate modifier, therefore, it is included within the global surgery package of procedure 69210 billed on the same date of service June 15, 2022. Therefore, we decided that the Plan does not have to pay for 
initial preventive physical examination (G0402) provided on June 15, 2022.