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

 
We decided that the Plan does not have to reimburse you for the walk-in bathtub (E1399) purchased June 16, 
2022. 
 
You asked the Plan to reimburse you for the walk-in bathtub. You say that you have net been able to do a sitz 
bath for about 20 years since the last knee replacement and you cannot get out on your own. Please reconsider 
the denial on the tub. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 reimburse you for the walk-in bathtub (E1399) purchased June 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple procedures 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 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 August 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a fecal occult blood test for colorectal cancer screening (G0328) 
provided on September 12, 2022. 
 
You asked the Plan to pay for a fecal occult blood test for colorectal cancer screening. You say that this was 
medically necessary. The Plan denied your request. The Plan says that this is only covered once every twelve 
months. 
 
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 rules also say that Medicare will pay for a covered fecal occult blood test (FOBT) (code G0328) 
at a frequency of once every 12 months. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Although the Plan has stated that this is covered once every 12 months, no 
documentation of when you last received this service was included in the file. Therefore, we decided that the 
Plan has to pay for a fecal occult blood test for colorectal cancer screening (G0328) provided on September 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 13, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on July 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoCel Allograft. 
 
You asked the Plan to pre-approve OsteoCel Allograft. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 OsteoCel Allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested OsteoCell Allograft, in 
this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OsteoCel Allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve OsteoCel Allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical osteogenesis stimulator. 
 
You asked the Plan to pre-approve an electrical osteogenesis stimulator. 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 the noninvasive stimulator device is covered only for 
specific indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electrical osteogenesis stimulator. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the electrical osteogenesis stimulator at issue in this 
case meets all of Medicare's NCD criteria for medically reasonable and necessary for the enrollee. Provided 
records do not document a failed fusion where a minimum of 9 months has elapsed since the last surgery or a 
congenital pseudarthrosis or a previously failed spinal fusion at the same site or a multiple level fusion as 
required by the NCD for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical osteogenesis stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (CPT code G0483) provided on July 21, 2021. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the testing is not necessary. 
 
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 drug testing have not been met. Ordering a multi-class panel of 
definitive (confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the 
enrollee. Under Medicare rules, the requested number of definitive urine drug classes are not medically 
necessary. There was sufficient information to manage the enrollee without definitive testing. Therefore, we 
decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes 
(CPT code G0483) provided on July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the services are not medically necessary at this time. Our physician reviewer found the 
request should be made after the 3-month period has past. If the pain relief is till greater than 50% at that point, 
then the request could be medically reasonable and necessary. This has to be documented clearly in order to 
proceed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy. 
 
You asked the Plan to pre-approve shoulder arthroscopy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 shoulder arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. The provided magnetic resonance 
imaging (MRI) does not corroborate any full-thickness tearing. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested right shoulder arthroscopy, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that these services were reported correctly. 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 August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies rendered on June 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 the transcutaneous electrical nerve stimulation (TENS) 
supplies rendered on June 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from June 11, 
2022, to July 10, 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 rules for payment for home health services have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, for all beneficiaries receiving HH services in 
2021 whose services will continue in 2022, the HHA shall submit an NOA with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. The HHA 
should submit the artificial admission date on all subsequent claims until the beneficiary is discharged and another NOA is required. 
 
We looked at the file and Medicare rules. In this case, the admission date on the claim at issue does not match 
the admission date on the submitted NOA. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services billed for dates of service from June 11, 2022, to July 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services from an inpatient rehab stay are 
medically necessary. The Plan denied your request. The Plan says the information they received shows an 
inpatient rehab stay is not medically necessary. 
 
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 that you do not require the intensity of services provided at an IRF.  Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  
Your care needs can be met at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted procedure, dentoalveolar structures (41899) 
provided June 16, 2022. 
 
You asked the Plan to pay for the dental service. You say that you ask for approval and processing for payment 
for the necessary medical services provided in the good faith to the enrollee. The Plan denied your request. The 
Plan says the surgical removal of multiple teeth, billed with CPT Code 41899, is not a Medicare benefit. 
 
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 pay for the 
unlisted procedure, dentoalveolar structures (41899) provided June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) and lead wires, (e.g., apnea monitor), per pair (A4557) provided April 4, 2022. 
 
You asked the Plan to pay for Electrical stimulator supplies. You say that say the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says evidence of 
misrepresented services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the delivery ticket submitted did include the 
carrier's tracking number, however, tracking is unable to be verified with USPS till now, tracking only shows 
the label created but not in system. The proof of delivery did not include an order number or details to 
corroborate the delivery ticket submitted. Also, the proof of delivery is not itemized to indicate the specific 
supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, 
per month, (e.g., TENS, NMES) (A4595) and lead wires, (e.g., apnea monitor), per pair (A4557) provided 
April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services identified with codes 56630, 88305, 88341, 88342, 
J1100, J1170, J1580, J2405, J2704, J3490, and J7050 provided on February 24, 2022. 
 
You asked the Plan to pay for services identified with codes 56630, 88305, 88341, 88342, J1100, J1170, J1580, 
J2405, J2704, J3490, and J7050. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 56630, 88305, 88341, 88342, J1100, J1170, J1580, J2405, J2704, J3490, and J7050 are 
not supported in the medical record. Specifically, status indicator C inpatient procedure code 56630 was billed 
on the outpatient claim. The remaining services were provided on the same day as inpatient procedure 56630; 
therefore, payment for this claim cannot be made. Based on this information, we decided that Medicare rules for coverage of services identified with codes 56630, 88305, 88341, 88342, J1100, J1170, J1580, J2405, J2704, 
J3490, and J7050 have not been met. Therefore, we decided that the Plan does not have to pay for services 
identified with codes 56630, 88305, 88341, 88342, J1100, J1170, J1580, J2405, J2704, J3490, and J7050 
provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 May 20, 2022.