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

 
We decided that the Plan does not have to pay for radiological services provided on September 22, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 76706 is Ultrasound, abdominal aorta, real time with 
image documentation, screening study for abdominal aortic aneurysm. 
 
We asked our coder 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 radiology services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the claim was billed with diagnosis code 
Z13.6, described as encounter for screening for cardiovascular disorders, which is not considered as appropriate 
diagnosis code for Ultrasound screening exam of abdominal aorta as per the above guidelines. Additionally, 
based on documentation received, it does not include that the patient received the screening study for one of the 
risk categories as listed in above guideline.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiology services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for radiological services provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulator provided on September 2, 
2022. 
 
You asked the Plan to pay for the device. The Plan denied your request. The Plan says the documentation 
submitted did not include a proof of delivery or a delivery ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation 
does not contain an itemized packing slip or delivery ticket for the date of service in question. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the electrical nerve stimulator provided on September 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided September 2, 2022. 
 
You asked the Plan to pay for the TENS device. You say that according to the prescription, the prescribing 
physician recommends an extended lifetime use of equipment as the enrollee is diagnosed with chronic pain 
and compromised mobility without the option for surgical correction. The Plan denied your request. The Plan 
says evidence of misrepresented services 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the documentation submitted did not include a 
proof of delivery, or a delivery ticket. 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 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that the enrollee must continuously check blood sugar. The 
Plan denied your request. The Plan says the enrollee was issued a CGM in August 2020 so a replacement 
device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of equipment due to wear is not 
covered within the reasonable useful lifetime of the equipment.  
 
We looked at the file and Medicare rules. The enrollee was already issued a CGM less than 5 years ago. 
Therefore, this item is still within its reasonable useful lifetime. The record does not show that the enrollees 
currently CGM has been lost or experienced irreparable damage. Based on this information, we decided that 
Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member will benefit from an IRF admission to 
optimize the level of function prior to returning home. The Plan denied your request. The Plan says criteria for 
an IRF admission have not been met. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies or an intensive rehabilitation therapy program. While the 
medical record supports a need for skilled therapy, there is no documented need for intensive rehabilitation 
services. The member can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services (A0431, A0436) provided on March 
26, 2022. 
 You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says these services were billed with the GZ modifier, 
and therefore are automatically denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules state that items submitted with a 
GZ modifier shall be denied automatically and will not be subject to complex medical review. 
 
We find that the ambulance services do not meet Medicare criteria for coverage. Specifically, these services 
were billed with the GZ modifier. Therefore, we decided that the Plan does not have to pay for air ambulance 
services (A0431, A0436) provided on March 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service October 4, 
2021. 
 
You asked the Plan to pay for procedure code(s) 88381. You say that this service was necessary and was 
reported correctly. 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) 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) 88381. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service October 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair accessory, power seating system, tilt 
only (E1002). 
 
You asked the Plan to pre-approve the power seating system, tilt only. You say that the enrollee had already 
received approval for the exact equipment. You are only submitting for a new prior authorization because the 
enrollee had switched insurance plans but kept the same member id. 
The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for the 
requested accessory. 
 
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 the power seating system, tilt only. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee requires a power wheelchair for mobility and accomplishing 
daily activities. However, the clinical documentation is insufficient as to why power tilt is required. The 
documentation indicates that the enrollee cannot independently perform pressure relief but is noted to have 4/5 
motor strength in the upper extremities with normal range of motion. The enrollee has no diagnosis that would 
not allow them to perform pressure relief. The enrollee has intact sensation in pressure bearing areas, does not 
have neurogenic bowel or bladder or require catheterization, and has no history of skin breakdown. The 
enrollee does not have lower extremity spasticity. The enrollee is noted to require assistance with transfers, but 
the level of assistance is not provided. Therefore, the power seating system, tilt only (E1002) 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 the power seating system, tilt only have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the wheelchair accessory, power seating system, tilt only (E1002).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 19, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on September 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided 
October 14, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you are requesting review of 
the medical records attached to show medical necessity and reconsider your claim for payment. The Plan 
denied your request. The Plan says the claim was received past the timely filing limitation. 
 
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 automatic external defibrillator was not filed until November 7, 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 the automatic external defibrillator (K0606) 
provided October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery (22551). 
 
You asked the Plan to pre-approve the spinal surgery. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the provided records do not support the requested procedure. 
 
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 the spinal surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found records do not show a trial and failure of recent less invasive conservative care measures. There 
is limited documentation of any formal physical therapy having been trialed and failed, or any injection 
therapies. 
 
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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve spinal surgery (22551).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 15, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinary tract infection (UTI) panel (codes 87900 and 87481) 
provided on June 8, 2022. 
 
You asked the Plan to pay for codes 87900 and 87481. You say that these services were necessary. The Plan 
denied your request. The Plan says the diagnoses billed on this claim do not support the medical necessity of 
these services. 
 
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 codes 87900 and 87481. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a bacterial urine culture is a laboratory procedure performed on a urine specimen to 
establish the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a urine culture. A urine culture may also be used as part of the evaluation and management of another 
related condition. The procedure includes aerobic agar-based isolation of bacteria or other cultivable organisms 
present, and quantification of types present based on morphologic criteria. Isolates deemed significant may be 
subjected to additional identification and susceptibility procedures as requested by the ordering physician. The 
review has determined that the items/services at issue in this case were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87900 and 87481 have not been met. Therefore, we decided that the Plan 
does not have to pay for urinary tract infection (UTI) panel (codes 87900 and 87481) provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingrix vaccine (90750) provided on September 29, 
2022. 
 
You asked the Plan to pay for the Shingrix vaccine. You say that the service was necessary. The Plan denied 
your request. The Plan says the service is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix 
vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed 
to any illness related to the Shingrix vaccine. Therefore, we decided that the Plan does not have to pay for the 
Shingrix vaccine (90750) provided on September 29, 2022.  
 
Benefits for the Shingrix vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and water 
circulating heat pad with pump (E0217) provided April 5, 2022, to April 26, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that please review and reconsider 
claim payment. The Plan denied your request. The Plan says a PCD coded as E0675 to treat peripheral arterial 
disease is not eligible for reimbursement and a water circulating heat pad with pump is not covered by 
Medicare.  
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. Also, it has not been established that a moist electric 
heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to 
a standard electric heating pad (E0210). Therefore, we decided that the Plan does not have to pay for a 
pneumatic compression device (E0675) and water circulating heat pad with pump (E0217) provided April 5, 
2022, to April 26, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0425, A0428, A0999) provided on October 16, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that this claim is missing a necessary secondary diagnosis and one 
code is missing a modifier. This claim must be corrected and resubmitted for payment. 
 
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. Specifically, the Plan did not include a copy of the original claim in the case file. 
Without the original claim, we cannot verify whether there are billing errors on this document. In addition, the 
Plan did not cite the specific Local Coverage Determination used to make their decision, and the case file notes 
that medical records were received for these services, but these were not included in the file sent to us for 
review. Therefore, we decided that the Plan has to pay for ambulance services (A0425, A0428, A0999) 
provided on October 16, 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 procedure code A4595 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code A4595. You say that you disagree with the denial. 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 A4595 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4595 is statutorily excluded. Based on this information, we decided that Medicare rules for coverage of procedure code A4595 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4595 billed for date of service September 15, 2022.