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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 16, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (TENS) device, 
four or more leads, for multiple nerve stimulation (E0730) provided June 7, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the prescribing physician recommends an 
extended lifetime use of equipment as they are diagnosed with chronic pain and compromised mobility without the option for surgical correction. The Plan denied your request. The Plan says neuromuscular electrical 
stimulation is not covered for the documented diagnoses. 
 
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 TENS device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found neuromuscular electrical stimulation is not covered for the documented diagnoses. The 
information provided with the appeal does not include any documentation of diffuse muscle atrophy where 
never supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, or other non-
neurological reasons for diffuse atrophy. 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 the TENS device have not been met. Therefore, we decided that the Plan does 
not have to pay for transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple 
nerve stimulation (E0730) provided June 7, 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 10, 2022, to 
April 8, 2022. 
 
You asked the Plan to pay for the home health services. You say that the medical records show medical 
necessity. The Plan denied your request. The Plan says the claim was not 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 looked at 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 have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from March 10, 2022, to April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept) procedure (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this treatment provides a treatment gap for 
those that do not receive adequate relief from traditional methods and do not have instability to indicate fusion 
is the appropriate treatment. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 
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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested Intracept procedure is considered experimental as more research is 
needed. Therefore, the reviewer found that the requested procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept) procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 therapeutic continuous glucose 
monitor (CGM) and monthly supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested supplies are medically 
necessary. The Plan denied your request. The Plan says you are not on insulin treatment with multiple daily 
administrations of insulin or continuous subcutaneous insulin 
infusion (CSII) pump. You do not meet criteria for coverage of the requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 therapeutic 
continuous glucose monitor (CGM) and monthly supplies (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the expandable controller, harness, and electronic connector. 
We decided that the Plan does not have to pre-approve gel pads.   
You asked the Plan to pre-approve the expandable controller (E2377), harness (E2313), electronic connector to 
2 power options (E2311), and gel pads (K0108). You say that the items are medically necessary. The Plan says 
that the items are not medically necessary. 
 
We decided that the Plan has to pre-approve the expandable controller, harness, and electronic 
connector.  
 
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 pre-approve the wheelchair accessories. Our 
reviewer says that the expandable controller with harness and electronic connection are medically necessary. 
Our physician reviewer found the patient cannot perform pressure relief independently due to weakness and 
requires a power wheelchair with power tilt and recline. The enrollee requires power elevating leg rests given 
their lower extremity spasticity and edema. They also have complex seating and positioning needs due to their 
lower extremity spasticity and kyphosis. This necessitates a more complex group 3 power wheelchair base. The 
expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base through the joystick. 
 
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 wheelchair accessories have been met. Therefore, we decided that the Plan 
has to pre-approve the expandable controller, harness, and electronic connector.  
 
We also decided that the Plan does not have to pre-approve gel pads. 
 
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 pre-approve gel pads. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (83789) billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for validity testing. You say that the service at issue has been billed correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing (83789) billed for date of service July 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus testing (U0003, U0005) provided on 
December 7, 2021. 
 
You asked the Plan to pay for the coronavirus testing. You say that you were advised that the enrollee's health 
plan should be responsible for paying this claim. The Plan denied your request. The Plan says the enrollees 
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on 
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 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 the coronavirus testing (U0003, U0005) provided on 
December 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent wheelchair van transportation (A0130) 
provided on July 13, 2022. 
 
You asked the Plan to pay for wheelchair van transportation. You say that you agree that this is not a covered 
service, but you need the Plan to reprocess the claim to allow you to hold the enrollee liable for services. The 
Plan denied your request. The Plan says the primary diagnosis submitted on this claim was not coded in 
accordance with Medicare guidelines, and the requested service is not payable per the Medicare Ambulance fee 
schedule. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergent wheelchair van transportation (A0130) provided on July 
13, 2022.  Your complaint about how the Plan processed this claim with no enrollee liability is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
September 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider was performing services and told 
me I needed this x-ray. 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. This benefit includes the 
requested bitewings - four radiographic images (D0274) but is limited to one of (D0270, D0272, D0273, 
D0274) per 12 months per patient. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested bitewings - four radiographic images (D0274) was exhausted on date of 
service June 28, 2022. Therefore, we decided that the Plan does not have to pay for bitewings - four 
radiographic images (D0274) provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64454 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 64454. You say that you disagree with the Plan's denial. 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 64454 is 2. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64454 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64454 billed for date of service May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 30, 2021 
to October 5, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
service was medically necessary. The Plan denied your request. The Plan says documentation does not support 
the billed diagnosis code. 
 
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. 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 records do not support the primary diagnosis code billed. Our physician reviewer 
found the enrollee was diagnosed with cholecystitis and underwent cholecystectomy. Upon evaluation, the 
patient was not in acute distress. There was no evidence of organ dysfunction related to a dysregulated 
systemic response from the infection. Sepsis criteria is not met.  
 
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 September 30, 2021 to October 5, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on May 30, 2022. 
 
You asked the Plan to pay for Tempus xF testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit.  
The Plan follows Medicare rules. Medicare rules say that Tempus xF testing is 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 pay for Tempus xF testing. Our reviewer says that 
the documentation does not support that the testing rendered was medically reasonable or necessary. Our 
physician reviewer found the enrollee has a lung mass biopsied to find poorly differentiated carcinoma, 
squamous cell carcinoma. The documentation shows that the enrollee's lung mass is new and is not a 
recurrence or a relapse of a prior cancer diagnosis. Also, the patient has not yet started treatment, so it is 
not refractory to prior treatments and there is no evidence provided to suggest it is advanced or metastatic. 
Therefore, the enrollee did not have a diagnosis/condition that met NCD criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xF testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the Tempus xF testing provided on May 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator, rental (E1392). 
 You asked the Plan to pre-approve a portable oxygen concentrator. You say that you are appealing the denial of 
your request for a portable oxygen concentrator. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for the requested device. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable oxygen concentrator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee has diastolic and valvular heart disease, and was recently 
hospitalized with heart failure and pulmonary edema and  was discharged on oxygen. Since discharge, the 
oxygen requirement has lessened, and the enrollee may be able to come off of oxygen in the near future. There 
is no testing to document that the enrollee is able to maintain SpO2 of 91% during activity using an oxygen 
conserving device at flow rate 1 - 4 L/min, as required by Medicare. A portable oxygen concentrator 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 a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator, rental (E1392).
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 
19, 2022. 
 
You asked the Plan to pay for procedure code 76641. 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 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

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