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

 
We decided that the Plan does not have to pay for the oral device provided on March 9, 2022. 
 
You asked the Plan to pay for the oral device. The Plan denied your request. The Plan says it cannot be 
determined how the enrollee came to the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the oral device have been met. The 
submitted documentation does not contain medical records from the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the oral device provided on March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump (E0784) and a 
continuous glucose monitor (CGM) with supplies (K0553). 
 
You asked the Plan to pre-approve an external ambulatory infusion pump and a CGM. You say that the 
enrollee is in need of diabetic supplies. Medical records are 
attached to prove medical necessity. The Plan denied your request. The Plan says the records do not document 
a C-peptide level; there is not a record of having been on an external insulin infusion pump, there is not a 
record of blood sugars being taken at least 4 times per day; and there is not documentation provided to show 
you have been using insulin at least three times per day and making frequent changes to your insulin dose for at 
least 6 months. The enrollee does not meet Medicare criteria for the requested pump and CGM. 
 
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 an external ambulatory infusion pump and a CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an external ambulatory infusion pump 
(E0784) and a continuous glucose monitor (CGM) with supplies (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane, Gemcitabine, and Ondansetron IV. 
 
You asked the Plan to pre-approve Abraxane, Gemcitabine, and Ondansetron IV. 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 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 Abraxane, Gemcitabine, and 
Ondansetron IV. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this case, the record indicates that the enrollee has a diagnosis of metastatic non-small cell lung cancer. The 
enrollee has previously been treated with carboplatin. The Food and Drug Administration has not stated that the 
requested drug 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 in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are 
not satisfied.  The requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane, Gemcitabine, and Ondansetron IV have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Abraxane, Gemcitabine, and Ondansetron IV.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43239). 
 
You asked the Plan to pre-approve an EGD. You say that the enrollee is due for the EGD, and it is medically 
necessary. The Plan denied your request. The Plan says the criteria for approval of an EGD have not been met. 
 
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 EGD. Our reviewer says that an 
EGD is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has short segment nondysplastic Barrett's esophagus. Our reviewer found that the guidelines say a 
repeat interval for Barrett's surveillance, based on the length of Barrett's epithelium, is medically necessary at a 
5-year interval, not the 3-year interval under review. Our physician reviewer also found that no clinical records 
were otherwise provided to support that the enrollee meets a medically necessary exception to standard-of-care 
criteria. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies (K0553, 
K0554) provided on August 10, 2022. 
 
You asked the Plan to pay for a CGM and supplies. You say that you disagree with the denial and are 
requesting reprocessing of the claim. The Plan denied your request. The Plan says the information submitted 
was insufficient for the dates of 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 physician order and proof of delivery for the supplies provided in this case. 
If the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record 
tracking the item(s) from the DMEPOS supplier to the beneficiary. 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 a continuous glucose monitor (CGM) and supplies (K0553, K0554) provided on 
August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 12, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 12, 2022.
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 June 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement between the laboratory and the dialysis facility regarding payment; therefore, separate payment must 
be made. 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 June 14, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical; cholecystectomy provided to the 
enrollee on June 14, 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 the submitted records do not include documentation of the billed service being performed on the 
date of service. 
 
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 47562 is "Laparoscopy, surgical; cholecystectomy." 
 
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 the provider reported reduced 
services, as well as assistant surgeon modifier 80. Reduced services are supported in the operative report; 
however, assistant surgeon for this procedure cannot be verified. 
 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 laparoscopy, surgical; cholecystectomy provided to the enrollee on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2083 billed for date of service May 17, 
2022. 
 You asked the Plan to pay for procedure code G2083. You say that the claim denied in error. 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 G2083 is 1. The MAI value for this code is 2. You billed 84 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code G2083 billed for date of 
service May 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hydration intravenous infusion and the electrocardiogram 
provided on July 14, 2022. 
 
You asked the Plan to pay for the hydration intravenous infusion and the electrocardiogram. 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 code 96361 is only covered when billed with 
specific diagnosis codes. 
 
We looked at the file and Medicare rules. Review of the file shows that code 96361 was billed with diagnosis 
codes R10.84 (generalized abdominal pain), R11.0 (nausea), and T78.80XA (allergy, unspecified, initial 
encounter). These codes are not listed as covered diagnosis codes for procedure code 96361. This means this 
code is not payable as billed.  
Code 93305 has a status indicator of Q1. Procedure code 99285 was billed on the same claim, with the same 
date of service, with a revenue code of 450. According to the I/OCE Quarterly Release Files, this gives CPT 
code 99285 a status indicator of V (clinic or emergency department visit). Therefore, procedure code 93005 
which has a status indicator of Q1, is not separately payable. 
 
Based on this information, we decided that Medicare rules for coverage of the hydration intravenous infusion 
and the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the 
hydration intravenous infusion and the electrocardiogram provided on July 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod 5 G6 pods.  
You asked the Plan to pre-approve Omnipod 5 G6 pods. You say that the items are necessary. The Plan denied 
your request. The Plan says the items requested is disposable. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is equipment that 
meets specific conditions.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Omnipod 5 G6 pods have not been met. Therefore, we decided that the Plan does not have to pre-
approve Omnipod 5 G6 pods.  
 
Benefits for Omnipod 5 G6 pods 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mental hospitalization. 
 
You asked the Plan to pre-approve a partial mental hospitalization. You say that the mental health department 
indicated you require the hospital service. The Plan denied your request. The Plan says the documented clinical 
findings do not justify the level of care requested. 
 
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 partial mental hospitalization. Our 
reviewer says that you do not meet the Medicare criteria for a partial mental hospitalization. Our physician 
reviewer found you have not been showing any dangerousness to yourself or others and have not been 
exhibiting severe psychological or psychiatric impairment requiring this level of care. Our reviewer found that 
you have not been showing any perceptual disturbance, psychosis or aggressive behaviors. Our physician 
reviewer also found that it does not appear medically necessary and reasonable to have psychiatric care 
provided at the partial hospitalization level of care rather than a lower level of care, as you have not had any 
suicidal or homicidal thoughts or behavioral disturbance and your symptomatology could be treated 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 a partial mental hospitalization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a partial mental hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the remaining 10 fractions of code G6015 and 10 
fractions of code 77014. 
 
You asked the Plan to pre-approve the remaining 10 fractions of code G6015 and 10 fractions of code 77014. 
You say that the additional 10 fractions of intensity modulated radiation treatment (IMRT) are medically 
necessary. The Plan denied your request. The Plan says the additional 10 fractions of intensity modulated 
radiation treatment (IMRT) are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the remaining 10 fractions of code 
G6015 and 10 fractions of code 77014. Our reviewer says that the additional 10 fractions of intensity 
modulated radiation treatment (IMRT) are not medically necessary. Our physician reviewer found the ASTRO Choosing Wisely campaign strongly advocates against greater than 10 fractions for palliation of bone 
metastases, which is in accordance with abundant studies, meta-analyses and Cochrane reviews. The need for 
greater than 10 fractions of radiotherapy is not justified in the case file and routinely prescribing greater than 10 
fractions for palliation of bone metastases is not furnished in accordance with accepted standards 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 the remaining 10 fractions of code G6015 and 10 fractions of code 77014 have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining 10 fractions of 
code G6015 and 10 fractions of code 77014.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care (99232) provided on March 29, 2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the separate billing of this claim is 
supported. The Plan denied your request. The Plan says that the payment for this service is included in the fee 
for the procedure. 
 
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. We find that the Plan has not substantiated their denial, as they have not 
specified or given any evidence for what procedure the denied code is supposed to be included in. Therefore, 
we decided that the Plan has to pay for the subsequent hospital care (99232) provided on March 29, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 4, 2022, to 
March 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 March 4, 2022, to March 
24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show one of covered diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested device is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has chronic obstructive pulmonary disease without documented bronchiectasis. The documents provided do not indicate that the enrollee has an enumerated condition for 
which coverage is available under the local coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Solid Tumor and Heme CGP panel test (81455) provided on 
August 3, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary to assist in the 
treatment, prognosis, and diagnosis of the enrollees cancer. The Plan denied your request. The Plan says the 
requested testing is not covered as the provider submitted an incorrect diagnosis code that is not listed on the 
Medicare LCD L37810. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. An LCD provides a guide in determining whether a service or item is 
covered. The records show that the provider submitted incorrect diagnosis codes per the Medicare LCD. Based 
on this information, we decided that Medicare rules for coverage of laboratory testing have not been met. 
Therefore, we decided that the Plan does not have to pay for Solid Tumor and Heme CGP panel test (81455) 
provided on August 3, 2022.