Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on November 20, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim denied incorrectly. You 
say that due to the patients condition, she was transferred to another facility for a higher level of care and this 
claim should not be bundled into a claim that was billed with a different provider, a different TIN, a different 
facility or a different specialty. The Plan denied your request. The Plan says that the Plan was previously billed 
by and paid another provider for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation to substantiate their 
denial. Therefore, we decided that the Plan has to pay for an emergency department visit provided on 
November 20, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on July 18, 2022. 
 
You asked the Plan to pay for lab test. You say that you have an exclusive agreement with the dialysis facility 
to provide testing. The Plan denied your request. The Plan says that this provider is out-of-network with the 
Plan and authorization was not obtained. 
 
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. The Plan did not submit a copy of the applicable Evidence of Coverage (EOC) 
for this case. Without the Evidence of Coverage, we cannot determine whether any network lock-in rule may 
apply to this service. Therefore, the Plan has not shown that its decision to deny payment for this service is 
correct or justified according to the enrollees contract with the Plan. Therefore, we decided that the Plan has to 
pay for laboratory testing provided on July 18, 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 procedure code 76641 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that multiple procedures were performed on this 
date. 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 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 7, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
according to Medicare guidelines an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were 
furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until August 30, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
August 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram. 
 
You asked the Plan to pay for an electrocardiogram. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on July 21, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for an electrocardiogram have not been met. Therefore, we 
decided that the Plan does not have to pay for an electrocardiogram.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple exams on the date 
in question. 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 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 CGM device and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related 
supplies have not been met. 
 
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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G6 CGM device and related supplies.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient physical therapy (PT) services provided on 
July 25, 2022. 
 
You asked the Plan to pay for the PT services. You say that the services should be covered. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the outpatient physical therapy (PT) services provided on July 
25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (22+ classes) provided to the enrollee 
on July 2, 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 documentation does not support 22 or more drug classes; only 15 drug classes were tested. 
 
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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
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 documentation shows 15 drug 
classes were tested, not 22. The records do not support that 22 or more drug classes were tested in this case. 
 
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 drug testing services (22+ classes) provided to the enrollee on July 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the requested power wheelchair is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of a power 
wheelchair have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a power wheelchair is covered when the criteria 
listed in the Medicare rules section of this letter have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power wheelchair have not been met. Specifically, the case record does not establish that the 
enrollee's home provides adequate access between rooms, maneuvering space and surfaces for the operation of 
the requested power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37248, 75820 and 75825 billed on May 26, 
2022. 
 
You asked the Plan to pay for procedure codes 37248, 75820 and 75825. The Plan denied your request. The 
Plan says procedure codes 37248, 75820 and 75825 are considered inclusive to procedure code 37238. 
  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 procedure codes 37248, 75820 and 75825 are column II codes to 
column I code 37238; however, procedure codes 37248, 75820 and 75825 were billed with a modifier.  
 
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 procedure codes 37248, 75820 and 75825. Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the procedure report describes treatment on the left lower extremity. The transluminal angioplasty and 
venography would be included in the intervention procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37248, 75820 and 75825 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 37248, 75820 and 75825 billed on May 26, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test provided on January 18, 2021. 
 
You asked the Plan to pay for the coronavirus test. You say that the service provided was not related to the 
enrollee's hospice diagnosis. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus test provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 23, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that this should be covered. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on May 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inflectra (infliximab) injections at 600mg every 6 
weeks. 
 
You asked the Plan to pre-approve the requested dosage of Inflectra. You say that the enrollee suffers from 
premature return of symptoms at the current dosage. It is felt that the requested dosage will provide better 
symptom control. The Plan denied your request. The Plan says the requested dosage is not supported for this 
medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the requested dosage of Inflectra. Our 
reviewer says that the requested dosage of Inflectra is not shown to be medically reasonable and necessary. Our 
physician reviewer found the Medicare-approved major drug compendia do not support the dose of Inflectra 6 
mg/kg every 6 weeks for treatment of ankylosing spondylitis with uveitis and axial spondyloarthritis as 
medically reasonable and 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 requested dosage of Inflectra have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Inflectra (infliximab) injections at 600mg every 6 weeks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty powered operated vehicle (K0813). 
 
You asked the Plan to pre-approve a scooter. You say that you need the requested scooter because you are 
unable to go outside with your current scooter. You would like to move around your mobile park, and you 
would like to pick up your medicine at the pharmacy. The Plan denied your request. The Plan says you have 
already received a group 2 powered scooter on October 6, 2022. The Plan also says Medicare will pay for 
equipment that is needed for use in the 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 rules also say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 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. The file also shows that you a group 2 
powered scooter and that scooter serves the same purpose as the requested scooter. Therefore, we decided that 
the Plan does not have to pre-approve a heavy duty powered operated vehicle (K0813).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for critical care (99292) provided on May 3, 2022. 
 
You asked the Plan to pay for critical care 99292. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that this add-on code is not eligible for payment because the 
appropriate primary procedure code has been denied. 
 
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. The Plan denied payment for code 99292 because the primary procedure code 
99291 was not covered. However, the record shows that the Plan did cover and pay for the primary procedure 
code 99292. Therefore, the Plan has not shown that its decision to deny payment for code 99292 on this basis is 
correct or justified. Therefore, we decided that the Plan has to pay for critical care (99292) provided on May 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 76700. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76700 is bundled into payment for code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 code 76700 billed for date of service July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM. You say that the requested item is more 
comfortable, and that the Plan's denial reason does not make sense. The Plan denied your request. The Plan 
says rules for coverage for DME have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that solely display results on a 
smartphone and do not have a stand-alone receiver or integration into an insulin infusion pump do not meet the 
definition of DME and will be denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 3 CGM have not been met. Specifically, we found that the requested item is a 
CGM that solely displays results on a smartphone and does not have a stand-alone receiver. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).