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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided March 
16, 2022, to April 15, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.  PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided March 16, 2022, to April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87500, 87640, 87651, 87653, 87798, 87641, 
87481, 87491, 87591, 87486, 87541, 87581, 87801, 87561, 87556) provided on May 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87500, 87640, 87651, 87653, 87798, 87641, 87481, 87491, 
87591, 87486, 87541, 87581, 87801, 87561, 87556) provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment rendered on July 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 items/services at issue were 
reimbursed by the Plan on August 5, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the oxygen equipment rendered on July 17, 2022.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 95940. We decided that the Plan does not have to pay 
for procedure codes 95861 and 95938.  
 
You asked the Plan to pay for procedure codes 95861, 95938 and 95940 billed for date of service November 
10, 2021.. You say that the services at issue have been billed correctly. The Plan says that rules for payment 
have not been met. 
 
We decided that the Plan has to pay for procedure code 95940.  
 
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 Plans denial rationale indicates that payment for code 95940 is 
bundled into the facility payment. However, we found that code 95940 has a professional/technical component 
indicator of 0. This means that this code does not have a technical component. Payment for this code is not 
included in the payment to the facility. 
 
The Plan has not provided any other rationales for denying code 95940. It is the Plans responsibility to 
substantiate its denial with evidence. In this case, the Plans denial has not been substantiated, so we must find 
in your favor. Therefore, we decided that the Plan has to pay for procedure code 95940.  
 
We also decided that the Plan does not have to pay for procedure codes 95861 and 95938. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 95861 and 95938 have not been met. Specifically, the records suggest that these 
services were rendered in a facility setting. Procedure codes 95861 and 95938 have a professional/technical 
component indicator of 1. This means that these codes have a professional and technical component. These 
codes have not been billed with the appropriate modifier to indicate that they are for the professional 
component. Payment for the technical component of these codes is included in the payment to the facility and 
is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for 
procedure codes 95861 and 95938. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more care than what you can get from 
home. The Plan denied your request. The Plan says you do not meet all the requirements for an IRF admission. 
 
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 your medical status does not require intensive physician and nursing oversight in an 
IRF. While you may benefit from additional multiple therapies, including physical and occupational therapy, 
the documentation does not reveal that you require this therapy on an intensive IRF level. 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 an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra. 
 
You asked the Plan to pre-approve Fasenra. You say that you have been having trouble breathing. You also say 
that you need this drug. The Plan denied your request. The Plan says the step therapy criteria have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Fasenra. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the required drugs. The reviewer found that there is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fasenra have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Fasenra.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. 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 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder triage test (81479) provided on April 19, 
2022. 
 You asked the Plan to pay for the CXbladder triage test. You say that this is a medically necessary diagnostic 
service. The Plan denied your request. The Plan says this testing is not covered for screening purposes. 
 
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 CXbladder triage test, 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 CXbladder triage test (81479) provided on April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that the item is medically necessary. The 
Plan denied your request. The Plan says that the item is not medically necessary. 
 
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 an electronic connection. Our reviewer 
says that the requested item is considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient is functionally non-ambulatory and requires a power wheelchair for mobility and 
performing their basic daily activities. The enrollee cannot perform pressure relief independently due to 
weakness and tremor and requires a power wheelchair with power tilt and recline for adequate pressure relief 
and positioning. The enrollee also requires power elevating leg rests for positioning and the lower extremity 
edema. The complexity of the enrolles seating and positioning needs necessitates a more complex group 3 
power wheelchair base. The electronic connection is necessary to operate the group 3 power wheelchair base 
and the power tilt and recline and power elevating leg rests via a joystick and this cannot be reasonably 
coordinated without the connection given the patients condition and need to simultaneously operate the power 
devices. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection (E2311).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70450 billed for date of service October 14, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question and this service is supported as billed. The Plan denied your request. The Plan says that the 
payment for code 70450 is included in the payment for code 70496. 
 
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 did not provide any claim documentation for the 
conflicting service. Although we do agree that generally the payment for code 70450 would be included in the 
payment for code 70496, we cannot verify that these services were provided to the same enrollee on the same 
date, nor can we confirm that these services were either performed by the same provider or providers of the 
same specialty within the same physician group. Without documentation for code 70496, the Plans denial is 
not substantiated in this case. Therefore, we decided that the Plan has to pay for procedure code 70450 billed 
for date of service October 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you cannot go outside with the wheelchair 
you have now because it is not made for outside use. Your wheelchair is hard to push in the winter. There is a 
senior center down the street, and you would like to go down there and meet friends. The Plan denied your 
request. The Plan says have evidence that you would be able to safely use a PWC. You must show good safety 
awareness and judgment to operate a PWC. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you cannot safely operate the PMD being requested. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Group 2 power wheelchair (K0823).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires at least 25 days at 
an LTACH for continued trach, oxygen weaning, daily assessment by doctors and aggressive therapy sessions. 
You say that the enrollee's care needs cannot be provided at a lower level of care as they are stable to transition 
to an LTACH for further management and care. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in the current 
hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76642-26-LT and 76642-26-RT billed for 
date of service October 17, 2022. 
 
You asked the Plan to pay for procedure codes 76642-26-LT and 76642-26-RT. You say that you disagree with 
the denial. 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 each of 
code 76642-26-RT and 76642-26-LT, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 76642-26-LT and 76642-26-RT have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 76642-26-LT and 76642-26-RT billed for 
date of service October 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immediate lymphatic reconstruction procedures. 
 
You asked the Plan to pre-approve immediate lymphatic reconstruction. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/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 immediate lymphatic reconstruction. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that lymphedema is known to be a common complication of breast cancer 
and its treatment. However, there is a lack of high-level evidence supporting the effectiveness of immediate 
lymphatic reconstruction in preventing secondary lymphedema. While immediate lymphatic reconstruction 
may prove to be effective in facilitating lymphatic drainage, future study is required to demonstrate short-term 
efficacy and long-term benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of immediate lymphatic reconstruction have not been met. Therefore, we decided 
that the Plan does not have to pre-approve immediate lymphatic reconstruction procedures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies 
described by codes A7035, A7036, A4604, A7039, A7045, A7046, A7028, A7029, A7030, A7031, A7032, 
A7033, A7038. 
 
You asked the Plan to pre-approve these services. You say that you use your device six to eight hours every 
night. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that accessories used with a PAP device are covered when 
the coverage criteria for the device are met. 
 
We looked at the file and Medicare rules. The file does not contain any documentation to support that the 
CPAP device and accessories meet the criteria for coverage. The Plan requested medical records but were 
informed from the durable medical equipment (DME) company that the last records they had were from 2019. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) 
supplies described by codes A7035, A7036, A4604, A7039, A7045, A7046, A7028, A7029, A7030, A7031, 
A7032, A7033, A7038.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 88305. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 88305 is bundled into payment for code G0416. 
 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 88305 
is a column II code to column I code G0416. 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 88305 billed for date of service June 22, 2022.