Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on August 23, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and was reported 
correctly. The Plan denied your request. The Plan says that this code is not supported in the medical record. 
 
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 G0482 is drug tests, definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the medical records support that 
between 15 and 21 drug classes were tested in this case. Based on this information, we decided that Medicare 
rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive 
drug testing (G0482) provided on August 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: 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 had a stroke and needs more assistance 
that can be provided in an IRF. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary, and the enrollee's needs can be met at a lower level of 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 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 that 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 not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 4, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a power scooter or power wheelchair (E1399). 
 
You asked the Plan to pre-approve repairs to a power scooter or power wheelchair. You say that the scooter is 
medically necessary, even vital, for your mobility, as you wear oxygen daily. The Plan denied your request. 
The Plan says the documentation does not support that you have a mobility limitation which prevents you from 
completing 
mobility-related activities of daily living in your home which cannot be satisfactorily compensated for by use 
of a cane, walker, or manual wheelchair. The Plan also says that you report that the device is needed for 
activities outside of the home. 
 
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. Specifically, you have advised that you need this 
power mobility device to go to appointments and the grocery store. 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 pre-approve repairs to a power scooter or power wheelchair (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Spin Life EW-36 recreational scooter 
 
You asked the Plan to pre-approve the scooter. You say that you are unable to walk and fell recently walking to 
the mailbox and you need an EW36 scooter. The Plan denied your request. The Plan says a brand name scooter 
is not medically necessary the enrollee does not meet the Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Spin 
Life EW-36 recreational scooter
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on July 27, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with 
the denial and are requesting reevaluation of the claims. The Plan denied your request. The Plan says the PCD 
is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home or in any 
setting. 
 
The Plan follows Medicare rules. The rules 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. The records also show that the enrollee used the 
equipment in the facility during and/or after surgery. Payment for this service would have been included in the 
facility DRG or PPS prospective payment. Therefore, we decided that the Plan does not have to pay for a 
segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic compression device 
(E0675) provided on July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on September 12, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with 
the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are covered in the home setting when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
The Plan follows Medicare rules. 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. The records also show that you billed with place of 
service 24, which is an ambulatory surgical center. Medicare rules say that for DME to be covered, it must be 
appropriate and be needed for use inside the home. Therefore, we decided that the Plan does not have to pay for 
a segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic compression device 
(E0675) provided on September 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 27335. The Plan denied your request. The Plan says payment for 
code 27335 is bundled into payment for code 27447. 
 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 27335 
is a column II code to column I code 27447. 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 27335 billed for date of 
service June 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 provided on August 4, 2022. 
 
You asked the Plan to pay for procedure code 71045. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 27, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 71045 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 71045 provided on August 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
facet injections 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says medical necessity has not been met. The enrollee can appropriately receive 
therapy at a lower level of care such as SNF. 
 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on January 11, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that this was denied because the services were rendered 
by a non-participating provider. You had assumed all was ok as you had seen this provider in January 2022 and 
was not notified of any differences in service coverage when you made your surgery checkup. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 the outpatient office visit provided on January 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided from June 22, 2022, to June 23, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that medically necessary services were rendered 
to the enrollee as ordered by a credentialed physician. You also say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says that the payment for this service is included in the fee 
for the procedure. 
 
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. We find that the Plan has not substantiated their denial, as they have not 
specified or given any evidence for what procedure the denied code is supposed to be included in. This means 
that the Plan has not provided a valid reason for denying payment of the inpatient services. It is the burden of 
the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so 
we must find in your favor. Therefore, we decided that the Plan has to pay for the inpatient services provided 
from June 22, 2022, to 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the member had multiple exams done on 
this date of service. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on August 1, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the packet shows 
not delivered and the Proof of Delivery is not itemized to indicate the specific supplies. 
 
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. The Plan argues that the packet shows that items were not delivered, and that the 
delivery ticket is not itemized. However, the records show that the items were delivered to the enrollee on 
August 5, 2022. The packing slip also shows which items were included in the delivery. The Plans has not 
provided documentation to substantiate its denial. Therefore, we decided that the Plan has to pay for the 
electrical stimulator supplies provided on August 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. 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 event monitors are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an 
implantable cardiac monitor (ICM). In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ICM in this enrollees 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 23, 2022. 
 
You asked the Plan to pay for the lab services. 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 all services (with two (2) exceptions), the 
POS code to be used by the physician or other supplier will be assigned as the same setting in which the 
beneficiary received the face-to-face service. 
 
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 office POS code. 
The records do not support that the sample was taken in an office setting. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on April 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cequa solution 0.09%. 
 
You asked the Plan to pre-approve Cequa solution 0.09%. The Plan denied your request. The Plan says Cequa 
is a self-administered drug, and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cequa solution 0.09%.  
 
  Benefits for Cequa solution 0.09% may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.