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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
September 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that your doctor advised that you 
needed the device to prevent blood clots but that the Plan might not cover it. It was not explained to you. You 
thought that meant they would not bill for it or that you would have some minor copay. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided September 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 48 one-way transportation trips when each one-way trip does not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on April 4, 
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 claim was already processed. 
 
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 July 20, 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 the service have not been met. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on April 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous (IV) infusions of alpha lipoic acid to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve IV infusions of alpha lipoic acid. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
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 
intravenous (IV) infusions of alpha lipoic acid 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services after your surgery. The Plan 
denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor Assay provided on December 
23, 2022. 
 
You asked the Plan to pay for the Tempus xT Solid Tumor Assay. You say that this testing should be covered. 
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels may be covered when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. Specifically, the provided documentation does not support that the 
enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this 
information, we decided that Medicare rules for coverage of the Tempus xT Solid Tumor Assay have not been 
met. Therefore, we decided that the Plan does not have to pay for the Tempus xT Solid Tumor Assay provided 
on December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308 x 4, 99309 x 2) provided 
from October 8, 2022, to October 29, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the services should be covered. The Plan 
denied your request. The Plan says there was not enough information to determine if the services were 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the nursing facility care have been met. 
Specifically, there were no medical records provided, despite the Plan making multiple attempts for them. 
Without medical records, we cannot determine if the services were medically necessary. Therefore, we decided 
that the Plan does not have to pay for the nursing facility care (99308 x 4, 99309 x 2) provided from October 8, 
2022, to October 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound dressings (A6207) provided on August 18, 2022. 
 
You asked the Plan to pay for the wound dressings. You say that the units billed were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 12 units of CPT code A6207 are not supported in the medical record. The medical record only 
supports 12 units of CPT code A6207. Based on this information, we decided that Medicare rules for coverage of the wound dressings have not been met. Therefore, we decided that the Plan does not have to pay for wound 
dressings (A6207) provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your provider informed you there is no 
way to fix your denture and that a new denture must be made. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 7, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on November 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility care visit. You say that you are requesting the denied claim be 
reconsidered for payment. The Plan denied your request. The Plan says no authorization was submitted prior to 
services 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 a nursing facility care visit provided on November 
28, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for continuous glucose monitor (CGM) supplies provided on September 
30, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that these supplies were provided to the patient and 
this claim should be paid. The Plan denied your request. The Plan says that the medical records submitted do 
not match the patient date of birth on the claim form. 
 
The Plan must follow Medicare rules. Medicare rules say that providers and suppliers must report an accurate 
date of birth for the patient in the appropriate field on the claim form. The Plan's sole rationale for denial in this 
case is that the patient's date of birth on the claim form does not match the date of birth on the medical records.  
This is true. The medical records indicate a birth year of 1956, and the claim form indicates a birth year of 
1954.  However, the error is NOT with the claim form.  We have confirmed via Medicare's own database that 
the patient's birth year is truly 1954.  The issue is with a data entry error in the medical records, and you are not 
the party who created those records. (The records were instead supplied by the patient's doctor- the error is with 
them).  Because there is no error with the date of birth that you entered on the claim, and because the Plan has 
supplied no other argument for non-coverage, we find that the Plan has not justified its denial in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM supplies have been met. Therefore, we decided that the Plan has to pay for continuous 
glucose monitor (CGM) supplies provided on September 30, 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 pay for the shoulder orthosis (L3660) provided on May 17, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the arm sling. You say that the enrollee was treated under emergency care and 
the product was provided. Please process the claim for payment with supportive medical records. 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 did not pre-approve the 
item/service at issue. An arm sling does not meet the definition of a brace as it is not a rigid or semi-rigid 
device. 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 shoulder orthosis (L3660) provided on May 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 8, 
2022, to November 4, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the patient was referred for these services by 
a network doctor. This claim should be reprocessed for payment. The Plan denied your request. The Plan says 
the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service October 8, 2022, to November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is diagnosed with chronic 
respiratory failure, and severe COPD. The medical records document his disease is worsening resulting in more 
exertional dyspnea. The Plan denied your request. The Plan says the request for continuation of the requested 
device is not medically necessary. A review of the current medical literature does not consider this device to be 
standard medical treatment for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD and 
was previously approved for a Life2000 device for 3 months, in order to provide time to get established with 
BiPAP. The Life2000 device is not a true ventilator, because it is not capable of providing full ventilatory 
support. Its intended use is during activity, and not to treat nocturnal hypoventilation and CO2 retention. There 
is inadequate evidence of the safety and effectiveness of this device in the treatment of COPD. 
 
We looked at this physician's review, the file, and Medicare rules. Please note that the Plan says in order to 
allow the enrollee time to get more appropriate DME, the Plan will approve 3 months as a grace period. The 
device is authorized from January 11, 2023, through April 11, 2023. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental surgical procedure (41899) provided on May 18, 
2022. 
 
You asked the Plan to pay for dental surgical procedure. You say that this was medically necessary. The Plan 
denied your request. The Plan says dental services provided in an outpatient hospital setting are not covered. 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, dental services received in an 
outpatient hospital setting are not a covered benefit. Therefore, we decided that the Plan does not have to pay 
for a dental surgical procedure (41899) provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on June 15, 
2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx testing. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the testing does not meet the 
requirements for benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the FoundationOne Liquid CDx testing 
have been met. Complete medical records from the treating physician are needed to determine the medical 
necessity of why the large number of genes were tested or how they will impact the enrollee's care. Therefore, 
we decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on June 15, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 4, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the service obtained 
by the member was rendered by a provider who is not under contract with the health Plan. The service was 
received from an ineligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on  
September 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 30, 2022, 
through July 8, 2022, and billed with diagnosis code A41.9-Sepsis, unspecified organism. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code A41.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support principal diagnosis of A41.9. 
 
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 primary diagnosis code A41.9-Sepsis, unspecified 
organism. 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 documentation does not support the primary diagnosis of 
A41.9. Our physician reviewer found the member presented with foot pain, in the setting of diabetes and drug 
abuse. On the left foot, the member was found to have a plantar ulcer, a dorsal abscess and associated cellulitis. 
The member received wound care and antibiotics.  There is no evidence that the enrollee had systemic issues or 
organ failure.  As such, A41.9-Sepsis, unspecified organism is not the appropriate primary diagnosis code.  
 
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 on June 30, 2022, through July 8, 2022, and billed with diagnosis code 
A41.9-Sepsis, unspecified organism.