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

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service April 29, 
2022. 
 You asked the Plan to pay for procedure code 88305. You say that this service was reported appropriately and 
is supported in the medical record. The Plan denied your request. The Plan says payment for code 88305 is 
bundled into payment for code 17313. 
 
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 88305 
is a column II code to column I code 17313. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88305 billed for date of service April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360, 88341, 88342 and 88381 billed for 
date of service January 27, 2022. 
 You asked the Plan to pay for procedure code(s) 88360, 88341, 88342 and 88381. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360, 88341, 88342 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360, 
88341, 88342 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88360, 88341, 88342 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88360, 88341, 88342 and 88381 billed for date of service January 27, 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 September 7, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like this claim reprocessed and 
approved for payment. 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 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 4, 2022, to July 3, 2022. 
 You asked the Plan to pay for SNF care. You say that this should be paid for. The Plan denied your request. 
The Plan says custodial services are not covered. 
 
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 pay for 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 did not have documented skilled nursing needs. It is unclear whether 
the enrollee received a new PEG tube on 6/4/2022, or whether this was an exchange of her prior feeding 
tube. The enrollee did not have documented skilled therapy needs. No therapy records are identified. Daily 
skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and long-term, could, as a practical matter, be 
provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from June 4, 2022, to July 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records 
document the enrollee/caregiver have been educated on the enrollee's disease process, proper diet, safety 
precautions and medications. No medical visit notes from the enrollee's treating physician are provided 
documenting a need for additional skilled nursing services. Records do not document the need for intravenous 
medications, new tube feeding or ostomy care or daily complex wound 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pad for water circulating heat unit, pump for water 
circulating pad, delivery/set up/dispensing services, the pneumatic compression device, the pneumatic 
compressor, and the appliance provided from February 16, 2022, to March 8, 2022. 
 
You asked the Plan to pay for the pad for water circulating heat unit, pump for water circulating pad, 
delivery/set up/dispensing services, the pneumatic compression device, the pneumatic compressor, and the 
appliance. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
items rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the pad for water circulating heat unit is non-
covered. The rules say that a pneumatic compression device coded E0675 is not covered. The rules also say 
that the pneumatic compressor and appliance are covered for certain indications. 
 
We looked at the file and Medicare rules. Specifically, these items are 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. Based on this information, we decided that Medicare 
rules for coverage of the pad for water circulating heat unit, pump for water circulating pad, delivery/set 
up/dispensing services, the pneumatic compressor, and the appliance have not been met. Therefore, we decided 
that the Plan does not have to pay for the pad for water circulating heat unit, pump for water circulating pad, 
delivery/set up/dispensing services, the pneumatic compression device, the pneumatic compressor, and the 
appliance provided from February 16, 2022, to March 8, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an x-ray provided to the enrollee on July 1, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says that the claim is inappropriately coded based on other claims already received. 
 
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's denial is very vague. The plan has not specified what claims were 
used to determine that this claim was denied inappropriately. The plan has not cited any specific denial reason 
in this case. Therefore, we decided that the Plan has to pay for an x-ray provided to the enrollee on July 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan provided to the 
enrollee on April 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
In this case, the CPT Code Manual definition of code 78815 is "Positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh." 
 
We find that CPT code 78815 is not supported in the medical record. Specifically, records were not provided to 
verify that these services were actually rendered. 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 a 
positron emission tomography (PET) scan provided to the enrollee on April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan injections. 
 You asked the Plan to pre-approve Hyaluronan injections. You say that you disagree with the plan's denial. The 
Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Hyaluronan injections are only covered for certain 
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 Hyaluronan injections. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has pain and a diagnosis of arthritis with evidence of swelling and 
effusion of the right knee. The documentation does not support that the enrollee has failed to respond to 
aspiration of the knee when effusion is present and intra-articular corticosteroid injection therapy when 
inflammation is a significant component of the patient's symptoms and intra-articular corticosteroids are not 
contraindicated, as required by the Local Coverage Determination (LCD). Therefore, the enrollee does not 
meet criteria for the requested injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronan injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hyaluronan injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve continued coverage. The Plan denied your request. The Plan says you do not 
meet the requirements. 
 
The Plan follows Medicare rules. Medicare rules say that positive airway pressure devices are only covered 
under certain medical 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 continued coverage. Our physician 
reviewer found that you have severe obstructive sleep apnea based on a polysomnogram (PSG) from March 3, 
2022. A CPAP was prescribed, However, there is no record of a follow up visit with documentation of benefit 
and compliance, as required by Medicare. Therefore, the request is not medically 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 continued coverage have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued coverage of a continuous positive airway pressure (CPAP) device.
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. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the clinical assessment does not support the 
expectation of a stay to be at least 25 days. The Plan says that the enrollee's needs are being met in the current 
acute 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 the enrollee appears to be more stable and improving and should only require short-
term additional acute care hospital services that can safely be provided at the current facility until more stable 
and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. Transfer to the LTACH is not medically necessary as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended.  
 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 oxygen concentrator (E1390) purchased on June 8, 2022. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you are requesting reimbursement of 
services rendered. The Plan denied your request. The Plan says Medicare and the Plan will only cover the 
rental of an oxygen concentrator from approved suppliers and will not cover the cost of purchasing one. 
 
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 oxygen concentrator have not been met. The rules say that only 
rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. 
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased on 
June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of genicular nerve blocks. 
 
You asked the Plan to pre-approve injection of genicular nerve blocks. 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 injection of genicular nerve blocks. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the role of genicular nerve blocks and radiofrequency ablation (RFA) is the 
subject of continuing clinical trials and is considered experimental/investigational. Therefore, the request is 
deemed not medically reasonable and 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 injection of genicular nerve blocks have not been met. Therefore, we decided 
that the Plan does not have to pre-approve injection of genicular nerve blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rental of a CPAP device provided from March 23, 2022, 
through July 23, 2022. 
 
You asked the Plan to pay for the DME. You say that you had an approved authorization and one denied 
authorization that an appeal has been started on. The Plan denied your request. The Plan says the medical 
criteria indicates that you must use your CPAP device for over 4 hours per night on 70% of nights during a 
consecutive 30-day period to be considered medically necessary. The Plan states the available medical 
documentation indicates you are not meeting device compliance. 
 
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 DME. Our physician reviewer found 
there is no documentation that the coverage criteria were met for the DME from June 23, 2022, through July 
23, 2022. Provided records do not document compliance data from June 23, 2022, through July 23, 2022. 
Provided medical records document compliance data for March 23, 2022, through June 20, 2022. Compliance 
during this period is reported as 9% for use of the CPAP for over 4 hours per night. The LCD: Positive Airway 
Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) requires use of the CPAP "for 
over 4 hours per night on 70% of nights during a consecutive 30-day period." Review of the file shows that the 
authorization for the DME was only approved through June 23, 2022. Furthermore, you were asked to pay 20% 
coinsurance for the DME from March 2022 through May 2022. The Medicare coverage criteria for the DME 
were not met from June 23, 2022, through July 23, 2022; therefore, you are asked to pay for the DME rental 
that was not previously authorized from June 23, 2022, through July 23, 2022. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pay for rental of a CPAP device provided from March 23, 2022, through July 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGM and supplies (CPT code(s): K0553 and K0554) 
provided on June 17, 2022. 
 
You asked the Plan to pay for the CGM and supplies. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are 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 CGM and supplies have not been met. CPT code(s): K0554, 
K0553 has an MUE value of 1, the provider billed 2 units from which one procedure code for each already paid 
under the claim. Therefore, we decided that the Plan does not have to pay for the CGM and supplies (CPT 
code(s): K0553 and K0554) provided on June 17, 2022.