Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 1, 2022, through 
March 30, 2022. 
 
You asked the Plan to pay for home health services. You say that the NOA was accepted on January 31, 2022, 
and you are appealing the claim. The Plan denied your request. The Plan says an appropriate NOA claim was 
not submitted for this period of care. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the NOA submitted is not for this episode of 
care. Therefore, we decided that the Plan does not have to pay for home health services provided from March 
1, 2022, through March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and related accessories. 
 
You asked the Plan to pre-approve a power wheelchair and related accessories. You say that this device is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been met for the requested power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 
 The file shows that the enrollees condition can be improved by a manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power wheelchair and related accessories.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 4, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 3, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on June 3, 2022 by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from October 12, 2021, through 
October 14, 2021, at DRG 682. 
 
You asked the Plan to pay for inpatient services at DRG 682. You say that the physician documented acute 
kidney injury possibly secondary to hypotension induced prerenal etiology. You say that it would be 
inappropriate to remove the diagnosis code because there was sufficient documentation of the enrollee's 
condition, and the claim should be paid as originally billed. The Plan denied your request. The Plan says 
principal diagnosis code N17.9 is not supported. 
 
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 principal diagnosis code N17.9, defined as acute 
renal failure, unspecified. 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 inpatient services 
at DRG 682. Our reviewer says that the medical records do not support principal diagnosis of N17.9. Our 
physician reviewer found the enrollee was brought in due to chest pains and there is a more appropriate 
principal diagnosis that should be documented  
 
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 services provided from October 12, 2021, through October 14, 2021, at DRG 682.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) Freestyle Libre 14 
system. 
 
You asked the Plan to pre-approve a CGM Freestyle Libre 14 system. You say that you disagree with the 
denial and have submitted medical documentation to support medical necessity of the CGM system. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for coverage of the CGM system. 
 
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 that the enrollee does not perform blood 
glucose testing at least four times per day, 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 Freestyle Libre 14 system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) Freestyle Libre 14 
system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcranial magnetic stimulation (TMS) therapy 
provided on April 19, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TMS therapy is covered for the indications 
established in the applicable LCD. 
 
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 TMS therapy is not medically reasonable and necessary. Our physician reviewer found that the case 
file does not contain documentation of a confirmed diagnosis of severe major depressive disorder (MDD), 
single or recurrent episode. In addition, there is no clinical documentation of a trial of an evidence-based 
psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without 
significant improvement in depressive symptoms as documented by standardized rating scales that reliably 
measure depressive symptoms. 
 
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 the transcranial magnetic stimulation (TMS) therapy provided on April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 10, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the claim did 
not include all the documentation to process the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that the claim did not include the appropriate DEX Z-Code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed, fixed height, with any type side rails, with 
mattress (E0250) provided December 2, 2021. 
 
You asked the Plan to pay for the hospital bed. You say that you are requesting reimbursement for the cost of 
renting a hospital bed. The Plan denied your request. The Plan says the request for payment did not include a 
prescription. This is required to consider 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 physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the written letter of medical necessity is dated 
April 27, 2022, however this is after the date of service, December 2, 2021. 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 hospital bed, fixed height, with any type side rails, with mattress (E0250) 
provided December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 70480. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70480 is bundled into 
payment for code 70450. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70480 billed for date of service May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (22+ classes) provided to the enrollee on 
February 10, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says only 21 drug classes were tested. 
 
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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
We find that code G0483 is not supported in the medical record. Specifically, this code requires documentation 
of 22 or more drug classes being tested. The records only show that 21 classes were tested. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for drug testing (22+ classes) provided to the enrollee on February 
10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve additional physical therapy services. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says additional physical therapy services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found that the requested therapy is generally accepted as a specific and effective 
therapy for your patellar fracture that required surgery. The most recent documentation dated May 12, 2022 
indicated that your knee range of motion was 118 degrees with flexion and that you were performing a walking 
program. There is limited clinical documentation provided regarding your current function with regards to 
mobility and motor strength. It is unclear if you have the need for continued therapy per objective outcome 
measures. Additionally, you have been performing home exercises and additional therapy would not be needed 
purely to establish a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve twelve additional physical therapy services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with capecitabine (J8521). 
 
You asked the Plan to pre-approve capecitabine. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules have not been met because the 
requested drug has been prescribed for an off-label and not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 capecitabine. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
FDA has not stated that the requested drug regimen is indicated for the enrollee's condition. The Medicare-
approved cancer-drug compendia do not contain a supportive citation for the use of the requested drug regimen 
in the enrollee's clinical situation. No literature from Medicare-approved cancer journals was submitted for 
review. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of capecitabine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with capecitabine (J8521).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive a copayment for an office visit provided on May 12, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to waive a copayment for the office visit. You say that you switched your primary care 
provider to the OON provider, and you should not have a copayment. The Plan denied your request. The Plan 
says the service was rendered by an OON provider and the change in status of the enrollee's primary care 
provider was not effective until after June 1, 2022. The enrollee was given an in-network provider to use but 
the enrollee did not use them. Per the enrollees EOC receiving care from an OON provider is not covered. 
 
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 waive a copayment 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 waive a copayment for these 
items/services. Therefore, we decided that the Plan does not have to waive a copayment for an office visit 
provided on May 12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36247-22-RT and 37211-22-51-RT billed for date of 
service April 27, 2021. 
 
You asked the Plan to pay for procedure codes 36247-22-RT and 37211-22-51-RT. You say that You did not 
provide a specific argument for coverage. The Plan denied your request. The Plan says that procedure codes 
36247-22-RT and 37211-22-51-RT are not supported in the medical record. For code 36247-22-RT, the 
operative report did not include documentation of increased procedural services of a selective catheter 
placement. For code 37211-22-51-RT, the operative report did not include documentation of a transcatheter 
therapy and arterial infusion for thrombolysis other than coronary or intracranial using any method. 
 
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 36247 is Selective catheter placement, arterial system; abdominal, pelvic or lower extremity artery 
branch.  The definition of code 37211 is Transcatheter therapy, arterial infusion for thrombolysis other than 
coronary or intracranial, any method, including radiological supervision and interpretation, initial treatment 
day.  
 
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 procedure codes 36247-22-RT and 37211-22-51-RT. Our 
reviewer says that the records support the billing of codes 36247-22-RT and 37211-22-51-RT. Our reviewer 
found the access to the superficial femoral artery (SFA) is a first order artery. However, the SFA access also 
gains access to the third order artery for the popliteal artery. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36247-22-RT and 37211-22-51-RT have been met. Therefore, 
we decided that the Plan has to pay for procedure codes 36247-22-RT and 37211-22-51-RT billed for date of 
service April 27, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided on March 26, 2021 to April 9, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says records do not support the service billed. 
 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 code 3E0L4GC. 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 care. Our reviewer says that the records provided do not support the 
procedure codes billed. Our physician reviewer found the records do not describe an introduction of other 
therapeutic substance into pleural cavity, percutaneous endoscopic approach. Procedure code 3E0L4GC is not 
supported.  
 
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 care provided on March 26, 2021 to April 9, 2021.