Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a seat lift mechanism. We decided that the Plan does not have to 
pre-approve a seat lift chair.  
 
You asked the Plan to pre-approve a seat lift chair and mechanism.. You say that the enrollee is having 
difficulty getting out of chairs without assistance. The Plan says that the chair itself is non-covered by 
Medicare, this provider may not be certified with Medicare, and the provider would not charge separately for 
the lift motor. 
 
We decided that the Plan has to pre-approve a seat lift mechanism.  
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed are met. 
 
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 seat lift mechanism. Our reviewer 
says that the enrollee meets criteria for a seat lift mechanism. Our physician reviewer found the certificate of 
medical necessity reports that the enrollee has arthritis of the hip or knee. This seat lift mechanism is included 
in the treating practitioner's course of treatment in order to improve the enrollee's condition. The medical 
records document that the enrollee is incapable of standing from a chair without assistance. The records 
document that the enrollee has the ability to ambulate, albeit with ataxia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of seat lift mechanism have been met. Therefore, we decided that the Plan has to 
pre-approve a seat lift mechanism.  
 
We also decided that the Plan does not have to pre-approve a seat lift chair. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism.  
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve 
a seat lift chair. 
 
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: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (93702). 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says that this service is experimental and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 bioimpedance spectroscopy. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found Bioimpedance spectroscopy (BIS) is a more accurate method of identifying which 
breast cancer survivors will need compression intervention compared with tape measurement to prevent 
chronic lymphedema, according to findings from a study published in Lymphatic Research and Biology. This 
service is supported in the medical literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have been met. Therefore, we decided that the Plan 
has to pre-approve bioimpedance spectroscopy (93702).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron. 
 
You asked the Plan to pre-approve Palonosetron. The Plan denied your request. The Plan says the 
documentation does not support or clarify that the enrollee will be getting, or meets criteria for use in highly 
emetogenic or moderately emetogenic chemotherapy, or is being used with other emetogenic chemotherapy, or 
is being requested for post-operative nausea and vomiting. The Plan also says that the enrollee does not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Palonosetron. Our physician reviewer 
found there is no documentation that the Palonosetron at issue in this case meets all Medicare criteria for 
medically reasonable and necessary, or safe and effective, for the enrollee. Our reviewer also found that the 
provided records do not document that the enrollee is receiving or will be receiving moderately or highly 
emetogenic chemotherapy (or has postoperative nausea and vomiting) as is required for use of Palonosetron.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is experimental and investigational. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
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 you disagree with the Plan's 
denial. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93312, 93320, and 93325 billed for date of 
service February 22, 2022. 
 
You asked the Plan to pay for procedure codes 93312, 93320, and 93325. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for code 93312 is bundled into payment for 
code 00567. 
 
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 93312 
is a column II code to column I code 00567. This claim has not been billed with an appropriate modifier to 
bypass the edit. In this case, we have confirmed that codes 93320 and 93325 are add-on codes and have not 
been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 93312, 93320, and 93325 billed for date of service February 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on June 23, 2022. 
 
You asked the Plan to pay for the ultrasound. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 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, the ultrasound, 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 
ultrasound provided on June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 9, 2022, billed with 
codes 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 9, 2022, billed with codes 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351, 81479.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from May 6, 
2021, to June 4, 2021. 
 
You asked the Plan to pay for home health services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for home health services have 
not been met. 
 
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. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the case 
record shows that the RAP for the period of care at issue was not submitted timely. Therefore, we decided that 
the Plan does not have to pay for home health services billed for dates of service from May 6, 2021, to June 4, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 73030 provided on December 6, 
2021. 
 
You asked the Plan to pay for the x-ray services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the code did not have an anatomical modifier appended. 
 
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 73030 is radiologic examination, shoulder; complete, 
minimum of 2 views. 
 
We find that CPT code 73030 is not supported in the medical record. Specifically, anatomic modifiers should 
be reported by providers. This code was not billed with an anatomical modifier. Based on this information, we 
decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that 
the Plan does not have to pay for the x-ray services coded 73030 provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. 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 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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD). The case summary 
indicates the enrollee was recently hospitalized for altered mental status, and arterial blood gas (ABG) was 
consistent with acute on chronic hypercarbic respiratory failure, but no date is given for that hospitalization, 
and no records are provided from the hospital stay. An office visit dated September 23, 2022 indicates the enrollee has been on a home ventilator since March 2022. Pulmonary function tests confirm severe obstructive 
lung disease with severe hyperinflation. This enrollee may benefit from bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an outpatient. This has not 
been tried and failed. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99231) provided on July 11, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 We looked at the file and Medicare rules. Payment for the requested services (99231) is included in the global 
surgery payment for the procedure (36556) provided on the same date of service. 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 the services (99231) provided on July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81355, 0031U, 0032U, 81227, 81230, 
81231, 81232, 0033U and 81479) provided on May 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing is FDA approved and should be 
covered. The Plan denied your request. The Plan says tests not ordered by the physician who is treating the 
beneficiary are not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. The Plan contacted the referring provider listed on the claim, and the 
provider advised that they did not order the genetic testing. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (81355, 0031U, 0032U, 81227, 81230, 81231, 81232, 0033U and 81479) 
provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on July 1, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
supported. 
 
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 the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a female external urinary collection device; pouch 
(A4328). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are requesting the continuation of 
the PureWick supplies to be covered, because the enrollee has congested heart failure, is on Lasix, has urinary 
tract infections, has total incontinence, and cannot walk without assistance. The Plan denied your request. The 
Plan says Medicare or the Plan do not cover incontinence supplies because they are disposable, non-reusable 
hygiene items and fall outside the scope of coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a female external urinary 
collection device; pouch (A4328).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service March 23, 
2022, to March 29, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that this was billed correctly. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service March 23, 2022, to March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 26340 and 73100 billed for date of service 
April 21, 2022. 
 You asked the Plan to pay for procedure codes 26340 and 73100. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for codes 26340 and 73100 is bundled into payment for 
code 20680. 
 
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 codes 
26340 and 73100 are column II codes to column I code 20680. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 26340 and 73100 billed for 
date of service April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the ventilator is to be used for the 
treatment of thoracic restrictive disorder secondary to lung resection. The Plan denied your request. The Plan 
says the request for a home mechanical ventilator set in AVAPS-AE-, iVAPS-AE or TTV-VAPS-AE that 
could be delivered by BiPAP is not covered. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a history of 
pulmonary hypertension and previous lung resection for necrotizing pneumonia. There is presumed restrictive 
lung disease, although there are no pulmonary function tests to assess severity.  There is no diagnosis of COPD 
or neuromuscular disease. The enrollee was recently hospitalized with acute respiratory failure due to 
pulmonary edema, and ABG was consistent with acute on chronic hypercarbic respiratory failure. The enrollee 
improved on BiPAP. There is no ABG done while stable to confirm chronic CO2 retention, but that seems 
likely, and the patient would likely benefit from BiPAP during sleep. This has not been tried and failed as an 
outpatient.  Medicare does not cover a home ventilator when used as BiPAP. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).