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

 
We decided that the Plan does not have to pre-approve the Life2000 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the Life2000 portable ventilator is 
medically necessary to help the patient manage their complicated respiratory needs at home. The Plan denied 
your request. The Plan says the patient does not have a condition for which a home ventilator is covered. In 
addition, the requested device (Life2000) is not a true ventilator because it is not capable of manually adjusting 
the amount of air. It is designed primarily for use during activity. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested home ventilator is not medically necessary. Our physician reviewer found in this case the 
record indicates that the enrollee has interstitial lung disease due to chronic hypersensitivity pneumonitis. The noted diagnosis is not enumerated in the rules as one for which coverage is available. Notwithstanding that fact, 
the provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Life2000 home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on April 
21, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 (E0676) provided on April 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 provided on October 26, 2021. 
 
You asked the Plan to pay for procedure code 99220. You say that the medical records support the billing of 
code 99220. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99220. 
 
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 99220 is Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit.  
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 code 99220. Our reviewer says that the medical 
records do not support the billing of code 99220. Our reviewer found the review indicates that the enrollee was 
admitted October 26, 2021, for an elective ureteroscopy. The review indicates that code 99220 was not 
supported in the medical records. Specifically, there was no comprehensive history or medical decision making 
of high complexity. 
 
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 code 99220 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99220 provided on October 26, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the enrollee 
does not meet the guidelines and can receive the care needed in another setting, such as home, a long-term care 
facility, or other outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that enrollee has had acute medical/functional status 
change and skilled nursing/therapy assessment would be 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on September 27, 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 Current Procedural Terminology (CPT) code 99152 (1 Unit) remains not supported. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that Medicare does not allow separate payment for anesthesia services performed by the physician who also furnishes the medical or surgical service. 
In this case, payment for the anesthesia service is included in the payment for the medical or surgical 
procedure.  The payment for the anesthesia service is included in the payment for the medical or surgical 
procedure. The reviewed documentation has determined that the use of CPT 99152 has not been supported by 
the records provided.  
 
We looked at this coder'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 moderate sedation services (procedure code 99152) rendered on September 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19328 billed for date of service October 31, 
2022. 
 
You asked the Plan to pay for procedure code 19328. You say that this service was medically necessary. 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 19328 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 19328 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 19328 billed for date of service October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0483) provided on June 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 80307, & G0483 is not supported in the medical record. Specifically, the lab request in 
the records does not specify exactly what tests are to be performed. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (80307, G0483) provided on June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on September 9, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this equipment was medically 
necessary. The Plan denied your request. The Plan says this device was used in the hospital setting and is not 
eligible for payment when used outside the home. 
 
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.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0673, E0675) provided on September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 86607 provided on April 14, 2022. 
 
You asked the Plan to pay for code 86607. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 86607 is blood bank physician services; difficult cross 
match and/or evaluation of irregular antibody(s), interpretation and written report. 
 
We find that CPT code 86607 is not supported in the medical record. Specifically, this code was billed with 
diagnosis code D63.1 (anemia in chronic kidney disease). This diagnosis code has a code first note, requiring 
the etiology code to be sequenced first. This code is not acceptable as the primary diagnosis. This means the 
code is not payable as billed. Based on this information, we decided that Medicare rules for coverage of code 
86607 have not been met. Therefore, we decided that the Plan does not have to pay for code 86607 provided on 
April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on September 23, 2022. 
 
You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says the 
member is entitled to one annual physical per calendar year. According to the members claim history, the 
member received an annual routine exam on March 18, 2022. The health Plan is under no obligation to pay for 
a second routine exam in the same calendar year. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on 
September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99232) provided on July 8, 2022. 
 
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 the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this inpatient service was 
billed with an outpatient place of service (21). Based on this information, we decided that Medicare rules for 
coverage of the inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for 
inpatient care (99232) provided on July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the enrollee needs this knee brace. 
 The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary 
because the records show the enrollee does not have knee instability, or a recent knee injury or surgery. 
 
The Plan follows Medicare rules. Medicare rules say that for coverage of the knee orthosis, the enrollee must 
meet the criteria listed in the rules section of this letter. 
 
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 knee orthosis. Our reviewer says that 
the enrollee does not meet criteria for coverage of the knee orthosis. Our physician reviewer found that based 
on the medical records provided there is no documentation that the knee orthosis (L1852) at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the enrollee. Provided records in this 
case do not document a recent injury to or a surgical procedure on the knee or evidence of knee instability 
documented by examination of the patient and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test) as required by the Local Coverage Determination (LCD) - Knee 
Orthoses (L33318). 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1852).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 10, 2022 to 
March 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. 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 January 10, 2022 to 
March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumococcal vaccine provided on May 20, 2021. 
 
You asked the Plan to pay for the pneumococcal vaccine. You say that  The Plan denied your request. The Plan 
says the member received the pneumococcal vaccine in 2016. The claim denied correctly due to exceeding 
frequency limits. 
 
The Plan contract covers the pneumococcal vaccine. The Plan says that the Plan covers the first shot at any 
time, and also covers a different second shot if its given one year (or later) after the first shot. 
 
We looked at the file and Plans rules. The file shows that you received a pneumococcal vaccine in 2016 and 
you have exceeded the frequency limits. Therefore, we decided that the Plan does not have to pay for a 
pneumococcal vaccine provided on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism, electric, any type (E0627) and sales 
tax (S9999) provided on July 10, 2022. 
 
You asked the Plan to pay for a seat lift. You say that you disagree with the denial of the claim. You also say if 
you are using any other lift chair, you still need assistance getting up. The Plan denied your request. The Plan 
says seat lifts are covered by Medicare; however, the provider is not under contract with the health plan and is 
not certified with Medicare. Also, sales tax is never covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism, electric, any type 
(E0627) and sales tax (S9999) provided on July 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 23, 2021, 
through December 28, 2021, and billed with diagnosis code J96.01. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J96.01 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J96.01. 
 
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 secondary diagnosis code J96.01-Acute respiratory 
failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis code J96.01-Acute respiratory failure with hypoxia. Our physician reviewer found the documentation 
does not consistently and completely support the assigned secondary diagnosis of J96.01. Therefore, diagnosis 
code J96.01-Acute respiratory failure with hypoxia is not the appropriate secondary diagnosis.  
 
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 December 23, 2021, through December 28, 2021, and billed with 
diagnosis code J96.01.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 TissueNext testing (81479) provided on September 7, 
2021. 
 
You asked the Plan to pay for Guardant360 TissueNext testing. You say that this test was medically necessary 
and was reported correctly. The Plan denied your request. The Plan says that this claim is missing the necessary 
Z-Code for this test. 
 
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 provide a full and complete copy of the original 
claim for this service. Without the full claim, we cannot verify whether or not the Z-Code was included for this 
service. The test at issue is listed as covered under the MolDX program. The Plan has not provided enough 
evidence to substantiate their denial. Therefore, we decided that the Plan has to pay for Guardant360 
TissueNext testing (81479) provided on September 7, 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.