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

 
We decided that the Plan does not have to pay for one additional unit each of procedure codes 87496, 87511, 
87532 and 87661 billed for date of service February 27, 2022. 
 
You asked the Plan to pay for procedure codes 87496, 87511, 87532 and 87661. You say that these services are 
supported as billed. The Plan denied your request. The Plan says only one unit of each of these codes is supported in the medical record. There is no additional documentation to support an additional study which was 
billed and therefore the second units of these codes remain denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 procedure codes 87496, 87511, 87532 and 
87661. Our reviewer says that the records provided do not support the billing of an additional unit of each of 
these codes. Our physician reviewer found that the medical record includes one laboratory report with each of 
these procedures documented for one unit; therefore, the additional units of service cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87496, 87511, 87532 and 87661 have not been met. Therefore, 
we decided that the Plan does not have to pay for one additional unit each of procedure codes 87496, 87511, 
87532 and 87661 billed for date of service February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that you do not agree with the denial. The 
Plan denied your request. The Plan says you do not meet coverage criteria for approval of the requested 
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.  
 
 
 
 
 
 
 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 manual wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is documentation that you have 
a personal mobility deficit that impairs participation in mobility related activities of daily living. Although the 
order form for the wheelchair states that you cannot self-propel the wheelchair, there is documentation that you 
have a caregiver who can provide assistance with the wheelchair, the provided medical records do not 
corroborate this. There is documentation on the wheelchair order form that your mobility deficit cannot be 
helped by the use of a walker or cane, the provided medical records do not corroborate this. The order form for 
the wheelchair states your home provides adequate access for the wheelchair, the provided medical records do 
not corroborate that your home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided as required by the Medicare rules. Your medical record must 
contain sufficient documentation of your medical condition to substantiate the necessity for the type and 
quantity of items ordered and for the frequency of use or replacement. The information should include your 
diagnosis and other pertinent information including, but not limited to, duration of your condition, clinical 
course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic 
interventions and results, past experience with related items, etc. 
 
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 manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair (K0001).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colonoscopy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve colonoscopy. You say that the services requested are medically necessary. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
colonoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on May 5, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was transported twice in one 
day. The Plan denied your request. The Plan says the modifier is automatically denied as non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes A0425 and A0428 were billed with the -GY modifier. Claims submitted using the GY 
modifier may be auto-denied. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance transportation services provided on May 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary and essential for the 
enrollee. The Plan denied your request. The Plan says this is not medically necessary. The services the enrollee 
needs can be provided safely in other settings. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara System (oscillation and lung expansion 
therapy) (E1399) and supplies (A9999). 
 
You asked the Plan to pre-approve a Volara System and supplies. You say that the enrollee is unable to use a 
vest at 74lbs with osteoporosis. The enrollee trialed Volara and tolerated it well. The Plan denied your request. 
The Plan says this device is not medically reasonable or necessary in this case. 
 
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 a Volara System and supplies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has cystic fibrosis (CF), with recurrent and persistent 
respiratory infections and difficulty clearing airway secretions. She reportedly does not tolerate high-frequency 
chest wall oscillation. The Volara System combined nebulization, positive end-expiratory airway pressure 
("lung expansioin"), and airflow oscillation. The enrollee already has a nebulizer, so that component is 
duplicative. There is no known role or expected benefit from "lung expansion" in the treatment of cystic 
fibrosis. The airway oscillation has not been demonstrated to be beneficial in the treatment of CF. 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 Volara System and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Volara System (oscillation and lung expansion therapy) (E1399) and 
supplies (A9999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018) and monthly supplies for use of device (K1019). 
 
You asked the Plan to pre-approve an external upper limb tremor stimulator and supplies. You say that the 
device is medically necessary. The Plan denied your request. The Plan says there is lack of evidence to support 
this device over traditional treatment of essential tremor. 
 
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 an external upper limb tremor 
stimulator and supplies. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found at the present time the literature on the 
requested device/technology is largely limited to the manufacturers pre-market studies of the device. The 
studies available to date were largely limited to small studies with limited evaluation periods and open label 
studies. These studies otherwise present methodological limitations which preclude conclusions on the overall 
efficacy of the requested technology. Furthermore, there is a need for further research to be done of the 
requested device in order to permit conclusions that the device "At least as beneficial as an existing and 
available medically appropriate alternative". In as much this cannot be said to meet the Medicare definition of 
medical necessity at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external upper limb tremor stimulator and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of 
the peripheral nerves of the wrist (K1018) and monthly supplies for use of device (K1019).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says IRF is not medical necessary, and a lower level of care 
might be appropriate such as home with continued home health services. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals (S5170). 
 
You asked the Plan to pre-approve home delivered meals. You say that you were not aware of this service at 
the time you were discharged. The Plan denied your request. The Plan says you do not meet the coverage 
criteria established for home delivered meals. 
 
The Plan must follow Medicare rules. Medicare rules say that meals may be offered as a supplemental benefit.  
 
We looked at the file and Medicare rules. The record shows that at the time you were discharged on July 20, 
2022, you had a principal diagnosis of non-ST-elevation myocardial infarction (NSTEMI). Based on this 
information, we decided that Medicare rules for coverage of home delivered meals have not been met. 
Therefore, we decided that the Plan does not have to pre-approve home delivered meals (S5170).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services provided on May 16, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
for medical necessity. The Plan denied your request. The Plan says that this claim has been billed with an 
incorrect date of service. 
 
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 case file does not show that the lab service does not meet any of 
the exceptions outlined in the Medicare ruling. Therefore, we decided that the Plan has to pay for the genetic 
testing services provided on May 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 6, 2022. 
 
You asked the Plan to pay for the testing services. You say that the results could alter the enrollee's continued 
treatment. The Plan denied your request. The Plan says the service is integral to the primary procedure. 
 
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. The testing described by billed code 83789 is considered specimen 
validity testing which is not separately payable. 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 laboratory testing provided on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on June 22, 2022. 
 
You asked the Plan to pay for the vision care. You say that this should be covered as part of the cataract 
surgery performed earlier this year. You say that this was part of a normal follow-up. You say that the cataract 
surgery was covered under my current plan. You also say that it was necessary to prescribe proper glasses after a successful surgery. The Plan denied your request. The Plan says Medicare does not cover routine eye exams 
or eye refractions. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Though the Plan 
has supplemental vision care coverage, the record shows that the services in this case were not for routine 
vision care. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on 
June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 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 pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation air-pulse 
generator system. 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation air-pulse generator system. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 high frequency chest wall oscillation 
air-pulse generator system. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found a high-frequency chest wall oscillation device is not medically necessary. This enrollee has 
chronic obstructive pulmonary disease (COPD) and cough, but there is no diagnosis of cystic fibrosis, 
bronchiectasis, or neuromuscular disease. Medicare does not cover this device in the treatment of COPD, 
because there is inadequate evidence of benefit. 
 
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 high frequency chest wall oscillation air-pulse generator system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation 
air-pulse generator system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 29, 2021, 
to December 7, 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 the 
documentation supports the inpatient hospital services as billed. The Plan denied your request. The Plan says 
the medical records that have been submitted do not support the services as 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 diagnosis code, J96.01, defined as 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 substantiate the 
diagnosis code J96.01 defined as acute respiratory failure with hypoxia. Our physician reviewer found that the 
patient had a history of asthma versus chronic obstructive pulmonary disease (COPD). They were admitted for 
the management of pneumonia and demonstrated one pulse oximetry reading of less than 90%. They were 
managed with nasal oxygen at 2L-to-3L/minute. Acute respiratory failure is more than a mild degree of 
hypoxia in a patient with chronic obstructive pulmonary disease and pneumonia who can be managed with 
low-flow supplemental oxygen. The review has determined that the documentation did not support the billed 
diagnosis code J96.01, defined as acute respiratory failure with hypoxia.  
 
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 November 29, 2021, to December 7, 2021, at the Diagnosis Related 
Group (DRG) originally billed.