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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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 enrollee does not meet criteria for a home ventilator. Our physician reviewer found the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine 
with average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a 
device is available upon request. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies (J2260, A4221, A4222) provided 
September 29, 2022 to October 6, 2022. 
 
You asked the Plan to pay for the infusion supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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 did not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Proof of delivery 
was not submitted to the plan with the original claim or for the first appeal. Therefore, we decided that the Plan 
does not have to pay for infusion supplies (J2260, A4221, A4222) provided September 29, 2022 to October 6, 
2022.
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. The Plan denied your request. The Plan says the request for the 
inpatient rehabilitation level of care exceeds your medical needs. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) 
device (E0730) provided on November 12, 2022. 
 
You asked the Plan to pay for the TENS device. You say that this claim should be covered. The Plan denied 
your request. The Plan says this device and supplies are not covered for chronic low back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that this device is not covered for chronic low back 
pain. 
 
We looked at the file and Medicare rules. The medical records show that this device has been requested to treat 
chronic low back pain. Based on this information, we decided that Medicare rules for coverage of the TENS 
device have not been met. Therefore, we decided that the Plan does not have to pay for the Transcutaneous 
Electrical Nerve Stimulators (TENS) device (E0730) provided on November 12, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 4, 2023, to  
February 1, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that you have been under the care of this psychologist 
for almost five years due to complicated trauma you experienced in 1970 due to sexual assault and you are at a 
crucial point in your therapy. You say that you have built a trust with this provider and believe it would be 
cruel and devastating to you to have to find a new therapist. The Plan denied your request. The Plan says the 
provider the enrollee utilizes is a psychologist with a master's level and with their own practice. The Plan 
cannot pay for services rendered by a non-Medicare eligible provider. 
 
The Plan contract covers mental health services provided by a state-licensed psychiatrist or doctor, clinical 
psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other 
Medicare-qualified mental health care professional as allowed under applicable state laws. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover mental health services 
provided by a psychologist with a masters level degree. Based on this information, we decided that the Plans 
rules for coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not have to 
pay for psychotherapy provided from January 4, 2023, to February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paring or cutting procedures on the skin (code 11056) 
provided on July 12, 2022. 
 
You asked the Plan to pay for paring or cutting procedures on the skin. The Plan denied your request. The Plan 
says paring or cutting of benign hyperkeratotic lesion is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of paring 
or cutting procedures on the skin have not been met. Therefore, we decided that the Plan does not have to pay 
for paring or cutting procedures on the skin (code 11056) provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on September 12, 2022, to 
September 16, 2022. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the number of units billed does not correspond 
with date span. 
 The Plan must follow Medicare rules. Medicare rules say that the unit of service on an institutional claim 
generally refers to the number of days in a given accommodation. The day of admission is counted, while the 
day of discharge is not.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital care provided have not been met. The number of days in the date span is 4 
days, not counting the discharge date. Only 3 days were reported on revenue code 0111, which refers to the 
days spent in an inpatient bed. This means that the number of units does not match the date span for this 
hospital stay. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on 
September 12, 2022, to September 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Nodify CDT testing (81599) provided on September 26, 
2022. 
 
You asked the Plan to pay for Nodify CDT testing. You say that this test was medically necessary and is a 
valuable tool for the enrollee's treatment. The Plan denied your request. The Plan says this test does not meet 
MolDX rules for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Nodify CDT testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Nodify CDT testing (81599) provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
October 3, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 01, 2020. The Plan 
denied your request. The Plan says that this code must be billed by the OTP facility on a facility claim. 
 
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 OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on October 3, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revascularization procedure (37220, 37225, 37221, 
37224). 
 
You asked the Plan to pre-approve the revascularization procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the revascularization procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the evidence does not provide documentation of severe arterial stenosis on non-
invasive studies. Moreover, the records do not show that guideline-directed medical therapy, such as or a 
program of structured exercise, has been carried out.  
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 revascularization procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a revascularization procedure (37220, 37225, 37221, 37224).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you need a power scooter to conduct your 
business outside your home. The Plan denied your request. The Plan says the scooter is not covered for use 
outside your 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 pre-approve a power scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the left ankle orthosis (L1971) provided on November 10, 
2022. 
 
You asked the Plan to pay for the ankle orthosis. You say that the ankle orthosis was medically necessary for 
the enrollee. The Plan denied your request. The Plan says the provided documentation does not support the 
billed supply code. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the left ankle orthosis (L1971) 
provided on November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (0241U) provided on December 5, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 laboratory testing (0241U) 
provided on December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for the BRCA1 and BRCA2 genes 
(81162). 
 
You asked the Plan to pre-approve genetic testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says genetic testing for the BRCA1 and BRCA2 genes is not covered when it is 
provided as a screening for an enrollee with no personal history of cancer. 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, genetic testing, is being requested solely for screening purposes, as you have no 
personal history of cancer. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pre-approve genetic testing for the BRCA1 and BRCA2 genes (81162).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
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 SSBCI benefits. Our reviewer says that 
you do not meet the coverage criteria for the requested SSBCI benefits. Our physician reviewer found that you 
have a history of diabetes mellitus, sleep apnea, and overweight. There is no documentation provided 
indicating that the enrollee requires intensive care management. As such, you do not meet the coverage criteria 
for the requested SSBCI benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI benefits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
November 11, 2021. 
 
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 99223-25 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 99223 is "Initial hospital 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 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the medical records 
submitted do not support a comprehensive history. 
 
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 initial hospital care (procedure code 99223) rendered on November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on October 1, 2022. 
 
You asked the Plan to pay for the supplies. You say that the records support the billed supplied code. The Plan 
denied your request. The Plan says that the proof of deliver is not valid. 
 
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 contains a valid proof of delivery for the supplies provided in this case. Therefore, we decided that 
the Plan has to pay for the electrodes (A4595) provided on October 1, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on September 8, 2022, billed with 
primary diagnosis code S12.000A, described as unspecified displaced fracture of first cervical vertebra, initial 
encounter for closed fracture. 
 You asked the Plan to pay for testing services provided. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says the services were billed with an invalid diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that a manifestation code cannot be billed as a 
primary diagnosis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of testing services provided have not been met. This claim was billed with diagnosis code S12.000, 
which is a manifestation code and cannot be billed as a primary diagnosis. Therefore, we decided that the Plan 
does not have to pay for testing services provided on September 8, 2022, billed with primary diagnosis code 
S12.000A, described as unspecified displaced fracture of first cervical vertebra, initial encounter for closed 
fracture.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on October 1, 2022. 
 
You asked the Plan to pay for the supplies. You say that the supplies were billed using the correct code. The 
Plan denied your request. The Plan says that the documentation provided does not support the billed supply 
code. 
 
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 contains a valid proof of delivery for the supplies provided in this case. Therefore, we decided that 
the Plan has to pay for the electrodes (A4595) provided on October 1, 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.