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) and segmental 
pneumatic appliance (E0673) provided May 20, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. You are not contracted 
with the facility or the prescribing physician and do not receive payment from either provider. 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) and segmental pneumatic appliance (E0673) provided May 
20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
August 11, 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 there is no valid proof of delivery. 
 
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 continuous glucose monitor (CGM) supplies rendered on 
August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on September 19, 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 were not billed with a valid primary diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 anesthesia services 
rendered on September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 13, 
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 more information is needed to consider this charge. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is only limited documentation provided. No provider narrative has been submitted for 
review. Therefore, there is no explanation as to why this test was ordered. The documentation does not support 
that the test was medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records indicate that a radionuclide stress test in August 2022 was 
negative for ischemia. The enrollee has not had a trial with anti-anginal therapy. Thus, the documentation does 
not support the rationale for this invasive imaging study. Guidelines do not support a need for cardiac 
catheterization in this setting. As a result, at this time cardiac catheterization 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 24, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says Medicare is 
responsible for hospice claims. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on June 24, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from July 12, 2022 to 
August 16, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that you chose this Medicare Advantage Plan 
because you believed this Plan was similar to the prior Plan you had when seeing this provider, and the Plan 
had no problem covering this provider's claims through the years. You say that you have been seeing this 
provider for prolonged grief/depression, and you hope that the Plan would reconsider paying this claim and 
help you find a way that you can continue appointments with her as it had taken a long time to find this 
therapist and she is the only one that you have come to trust. The Plan denied your request. The Plan says a 
marriage family therapist is not listed as an eligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist 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 Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from July 12, 2022 to 
August 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 27, 2022, to 
September 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the NOA 
and only one is required per admission. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 27, 2022, to 
September 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care rendered on May 18, 2021. 
 
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 claim was not billed with a valid primary diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 initial observation 
care rendered on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided from June 10, 2022, to June 15, 
2022. 
 
You asked the Plan to pay for the medical supplies. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not supply an itemized shipping invoice or proof 
of delivery to support payment. 
 
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 packing slip listing the specific supplies provided or a proof of delivery for 
the supplies provided in this case. 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 medical supplies 
provided from June 10, 2022, to June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99072, A4556, A4557, A4649*3, A9279, 
S1015, S8301, & A4624 billed for date of service September 6, 2022. 

You asked the Plan to pay for procedure codes 99072, A4556, A4557, A4649, A9279, S1015, S8301, & A4624. You say that these services were medically necessary. The Plan denied your request. The Plan says procedure codes 99072, A4556, A4557, A46493, A9279, S1015, S8301, & A4624 are not payable as billed.

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 99072 has a status indicator of B on the Physician Fee Schedule. Codes A4556, 
A4557, A4649 have a status of "P". Payment for these codes is bundled into another service. Codes A9279, 
S1015 and S8301 have a status of "I" and are not recognized by Medicare for payment.  Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99072, A4556, A4557, A4649*3, 
A9279, S1015, S8301, & A4624 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 99072, A4556, A4557, A4649*3, A9279, S1015, S8301, & A4624 billed for date of 
service September 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 9, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until August 8, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
January 9, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on July 25, 2022. 
 
You asked the Plan to pay for the services. You say that the testing being performed is a once in a lifetime test 
which also meets the criteria for frequency limitations. The Plan denied your request. The Plan says that this 
was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that molecular profiling in patients suspected of myeloid neoplasms is considered a standard of care. Its 
use is supported by the National Comprehensive Cancer Network (NCCN) guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
laboratory services provided to the enrollee on July 25, 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 pneumatic compression device provided on May 23, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that You say that this item was 
issued to the patient for use during their surgery.  You stated that you do not receive payment from the facility. 
The Plan denied your request. The Plan says this item is not covered. 
 
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. Medicare does not consider a SNF, a hospital, or an ambulatory surgical 
center to be a home. Medicare rules also say that pneumatic compression devices that provide intermittent limb 
compression for the purpose of prevention of venous thromboembolism are excluded from coverage under the Medicare DME benefit. 
 
Records show that the pneumatic compression device was used in an ambulatory surgical center. Further, the 
records show that the pneumatic compression device at issue was provided for the prevention of venous 
thromboembolism during surgery.  Medicare does not cover this item for that purpose. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression device provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010-GP billed for dates of service August 
26, 2022 to August 31, 2022. 
 You asked the Plan to pay for procedure code 97010-GP. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 97010-GP is considered bundled 
and 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 procedure code. 
 
We find that procedure code 97010-GP has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 97010-GP is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 97010-GP have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 97010-GP billed for dates of service August 26, 2022 to August 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. 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 no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless 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 a SCS trial. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no psychological evaluation or surgical consultation. The request does not meet the NCD criteria. The request is 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 a SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 23, 2022 to 
September 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided the NOA. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 23, 2022 to 
September 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry services billed with code 88188 for date of 
service April 27, 2022. 
 
You asked the Plan to pay for code 88188. You say that this service was medically necessary. The Plan denied 
your request. The Plan says you did not bill this service with a covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that that only claims billed with a covered diagnosis 
to support medical necessity for code 88188 will be paid. The only diagnosis you billed on this claim (D11.0- 
Benign neoplasm of parotid gland) is not listed as a covered diagnosis for code 88188. Based on this 
information, we decided that Medicare rules for coverage of code 88188 have not been met. Therefore, we 
decided that the Plan does not have to pay for flow cytometry services billed with code 88188 for date of 
service April 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 4, 2022 to 
April 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA, so this claim should be paid. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 4, 2022 to April 
2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance used with a therapeutic continuous 
glucose monitoring (CGM) device (K0553) provided July 11, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that please see attached medical records. 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Specifically, the USPS packet shows the item as not delivered. Therefore, the proof of delivery is not verified. 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 supply allowance used with a therapeutic continuous glucose monitoring (CGM) device 
(K0553) provided July 11, 2022.