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

 
We decided that the Plan does not have to pay for the Continuous positive airway pressure (CPAP) wipes 
(A9270) provided on October 19, 2021. 
 
You asked the Plan to pay for the CPAP wipes. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says CPAP wipes are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the Continuous positive airway pressure (CPAP) 
wipes (A9270) provided on October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvis or hip joint procedure (27299) provided on August 
20, 2021. 
 
You asked the Plan to pay for the pelvis or hip joint procedure (27299). You say that no CPT code accurately 
describes the services, but the services provided were medically necessary. You say that the operative report 
supports payment of the very necessary procedure, and you are entitled to be reimbursed fairly for those 
services. The Plan denied your request. The Plan says the billed procedure code is not on the covered 
Ambulatory Surgical Center procedure. 
 
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 27299 is unlisted procedure, pelvis or hip joint. 
 
We find that CPT code 27299 is not supported in the medical record. Specifically, CPT code 27299 is not a 
covered procedure when performed in an ambulatory surgical center. Based on this information, we decided 
that Medicare rules for coverage of the pelvis or hip joint procedure (27299) have not been met. Therefore, we 
decided that the Plan does not have to pay for the pelvis or hip joint procedure (27299) provided on August 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
September 23, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99153). You say that CPT code 99152 and 
99153 is the medication that was administered to the patient and CPT code 99153 should not be denied because 
of the place of service. You say that the documents should be reviewed, and the denial should be reversed. The 
Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 99153 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; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on September 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the hospital wants you to go home but you feel 
it will not be safe. The Plan denied your request. The Plan says this request is not medically necessary. 
 
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 services. Our reviewer says that 
you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93970) provided on June 15, 2021. 
 
You asked the Plan to pay for the extremity study. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation does not support that this 
service was rendered more than once on the billed 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 93970 is duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study. 
 
We find that CPT code 93970 is not supported in the record. Specifically, the documentation submitted does 
not show that this provider rendered a duplex scan of extremity veins on the billed date of service. Based on 
this information, we decided that Medicare rules for coverage of the extremity study have not been met. Therefore, we decided that the Plan does not have to pay for the extremity study (93970) provided on June 15, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 
14, 2021, to July 22, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. The rules say the Type of Bill is a required 
data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of 
information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this 
bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment 
are either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Based on 
this information, we decided that Medicare rules for completing the claim for home health services have not 
been met. Additionally, the claim is missing an appropriate G code and Q code per Medicare guidelines. 
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from July 14, 2021, to July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a continued SNF admission. The Plan denied your request. The Plan says 
your request for approval of continued admission in a SNF does not meet the requirements for approval. 
 
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 a continued SNF admission. Our 
reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found 
the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of a continued SNF admission have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continued skilled nursing facility (SNF) admission.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee needs to attend his medical 
appointments. The Plan denied your request. The Plan says you are requesting an additional 9.9 miles for a 
total of 59.9 miles and your benefit only allows 50 miles. The Plan also says you have exceeded your benefit 
limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 100 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional non-emergent 
routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for spine injection (77003) 
provided on October 2, 2020. 
 
  You asked the Plan to pay for the fluoroscopic guidance for spine injection (77003). You say that the 
fluoroscopic procedure was performed as a separate service to locate spinal cord stimulator leads. You say that 
the service is medically necessary, and the claim should be reconsidered for payment. The Plan denied your 
request. The Plan says CPT code 77003 was not billed with an appropriate primary code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
fluoroscopic guidance for spine injection (77003) is an add-on code and has not been billed with an appropriate 
primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the fluoroscopic guidance for spine injection (77003) 
provided on October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While the 
enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (including elevation of a full thickness 
flap and closure)  four or more contiguous teeth (D4260). 
 
You asked the Plan to pre-approve osseous surgery. You say that you would like the Plan to reconsider. You 
also say the procedure is to eliminate gum disease which is linked to heart disease. You have had open heart 
surgery and you feel this is essential for your overall health, not just your teeth. The Plan denied your request. 
The Plan says the requested service is not listed as a covered service under your contract under any 
circumstance. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (including elevation of a full thickness flap and closure)  four or more contiguous teeth 
(D4260).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transthoracic Echocardiography (TTE) with complete 
doppler (93306). 
 
You asked the Plan to pre-approve the diagnostic test. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the requested diagnostic testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that initial evaluation of patient with suspected pulmonary 
embolism in order to establish diagnosis is deemed to be not medically necessary. 
 
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 diagnostic test. Our reviewer says 
that the requested diagnostic test is not medically necessary. Our physician reviewer found without additional 
physical findings such as jugular vein distention (JVD) found on examination (not documented), there is 
insufficient support made for ECHO with doppler to evaluate for heart failure at this time. Therefore, this 
request for such will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the diagnostic test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Transthoracic Echocardiography (TTE) with complete doppler (93306).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from April 7, 2021, to 
April 12, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee was provided services in good faith. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 7, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care 
provided from April 7, 2021, to April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump (99190 and 99191), 
autologous blood or component (86891) and red blood cells (P9022) provided on July 5, 2021. 
  You asked the Plan to pay for assembly and operation of pump (99190 and 99191), autologous blood or 
component (86891) and red blood cells (P9022). You say that the patient did not have a choice of Perfusion 
providers because our service was arranged directly with the surgeon and facility. You say that the claim 
should be reprocessed according to the patients in- network level benefits since the services are considered 
medically necessary. 
 
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 codes 99190, 99191, 86891 and P9022 are not supported in the medical record. Specifically, 
services furnished to inpatients must be furnished by the hospital or billed through the hospital. Based on this 
information, we decided that Medicare rules for coverage of assembly and operation of pump (99190 and 
99191), autologous blood or component (86891) and red blood cells (P9022) have not been met. Therefore, we 
decided that the Plan does not have to pay for assembly and operation of pump (99190 and 99191), autologous 
blood or component (86891) and red blood cells (P9022) provided on July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
September 2, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that the claim 
reimbursement was well below the amount billed and you demand immediate payment of 30% of the billed 
charges. The Plan denied your request. The Plan says bundled services are not eligible for separate payment. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. 
  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials (99072) 
have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and 
materials (99072) provided on September 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 0.5mg Adempas tablets. 
 
You asked the Plan to pre-approve the Adempas tablets. You say that you would like reconsideration because 
this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under 
Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 0.5mg Adempas tablets.  
 
Benefits for the Adempas tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.